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Copyright N 0 _ 


COPYRIGHT DEPOSIT 
















PRACTICAL 



AND ITS SURGICAL TECHNIC 


BY 

ROBERT EMMETT FARR, M.D., F.A.C.S. 

ir 

MINNEAPOLIS, MINN. 


ILLUSTRATED WITH 219 ENGRAVINGS AND 16 PLATES 



> > 

I > 

) ■) > 

-> 




> 


LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 

1923 








Copyright 
LEA & FEBIGER 
1923 



< • 


PRINTED IN U. S. A. 


MAY-7’23 


©Cl (00529? 


TO 


WHO, 


THAT UNFORTUNATE INDIVIDUAL 

THE PATIENT 

FATE HAS DECREED, MUST UNDERGO SURGICAL 

THIS VOLUME 

IS SINCERELY DEDICATED 


TREATMENT 


3 




PREFACE. 


This book is an expression of the author’s views on the subject 
of local anesthesia as developed by his observation and by his own 
experience. Its aim is to present to the medical profession the 
advantages of local anesthesia to patient and to surgeon, and to 
describe the practical details of methods of administration and of 
operative technic employed in its use. As far as possible, stress has 
been laid upon the particular methods which have proven best 
in the author’s experience. Spinal anesthesia has been omitted as 
his experience with it has been limited. Every effort has been made 
to portray, in as vivid a manner as the ability of the author permits, 
the simplest and most efficient means of using local anesthesia. At 
the risk of being tedious, by introducing what might be considered 
an unnecessarv amount of detail, the author has endeavored to 
present the methods which have carried him through the critical 
stages of the various operations. 

Illustrations in the form of drawings and photographic reproduc¬ 
tions have been freely used wherever they were considered of advan¬ 
tage in helping to clarify the text. To illustrate the feasibility of 
performing the various types of operation under local anesthesia, 
case reports have been inserted. 

For the sake of convenience the book is divided into three parts: 

In Part I, consisting of Chapters I to VI, inclusive, certain problems 
are considered in connection with anesthesia, including equipment, 
technic and a description of the sensory nervous system. 

In Part II, which comprises Chapters VII to XII, inclusive, the 
subject has been considered regionally, all portions of the body, 
aside from the abdomen, being treated. 

In Part III, which includes the final six chapters, the surgery of 
the abdomen is considered. 

It is the author’s belief that the actual method of operating has a 
most important bearing upon the success which will attend any 
surgical procedure under local anesthesia. Hence points in surgical 
technic have been described with more than ordinary detail. It is 
hoped that sufficient descriptive material regarding both the technic 
of administering anesthesia and the technic of operating has been 
introduced to point the way with clarity and encourage the surgeon 
to adopt a certain degree of uniformity in his methods. 


VI 


PREFACE 


The necessity for teamwork among assistants in the treatment of 
patients and the importance of the psychic factor have been espe¬ 
cially considered. 

The author wishes to express his appreciation of the loyal and 
untiring efforts of his associates, who have so willingly worked 
with him in an effort to broaden the application of the local anes¬ 
thesia method. Especial thanks are due to Drs. S. R. Maxeiner, 
E. W. Gilroy (deceased), M. E. Rose and C. W. Brunkow: Dr. 
Maxeiner, who, first as assistant and later as associate, aided the 
author greatly, especially in the study of the nervous system 
upon the cadaver; Dr. Gilroy for his experimental work on the 
toxicity of the local anesthetics; and Drs. Rose and Brunkow for 
their study and observation regarding the alkaline reserve in rela¬ 
tion to local anesthesia and special aid in preparing Chapters I 
and II. 

The author desires also to acknowledge the many courtesies ex¬ 
tended by Dr. Charles A. Erdman, of the University of Minnesota, 
whose kind offices made it possible to carry out studies in the 
anatomical laboratory. He is also indebted to Dr. Paul W. 
Wipperman for proofreading the manuscript and offering many 
valuable suggestions in relation thereto. 

His thanks are also due to Miss Ann Nyquist, I\. N., his former 
and first psycho-anesthetist, whose efficient services and initiative 
made manifest the great advantages offered by this now indispens¬ 
able aid. 

In the assembling of this volume the tireless and painstaking 
efforts of Dr. Brunkow, Miss Ella May Thompson, R. N., who is now 
the author’s psycho-anesthetist, and his faithful secretaries, Miss 
Blanche W. Scallen and Miss Helen J. Cribb, R. N., have been 
invaluable. The author’s thanks are due to the artist, Mr. Ralph L. 
Witherow, by whom most of the drawings were made. He wishes 
also to express his thanks to Messrs. Lea & Febiger for the care 
exhibited and the many helpful suggestions in publishing this book. 

To the master technician in local anesthesia, this work will, 
perhaps, make no appeal, but it is the author’s hope and desire that 
this book may, in some small degree, help the less experienced to 
avoid the many pitfalls which the writer has encountered in his 
own experience with local anesthesia. Furthermore, it is his firm 
conviction that a simple presentation of the subject, such as this 
aims to be, will enable the earnest and interested student to 
improve, to some extent, his ability to use this form of anesthesia, 
thus increasing his efficiency and providing greater safety and com¬ 
fort for his surgical patients. 

R, E. F. 

Minneapolis, Minn., 1923 . 


FOREWORD. 


The writer, having been selected twenty years ago to review 
the progress and present the status of Local Anesthesia before an 
International Congress, experiences peculiar pleasure in the oppor¬ 
tunity, here afforded, to review again in this masterpiece the enor¬ 
mous progress made in both the art and science of Local Anesthesia. 

With the announcement of the discovery of the first drug (cocain) 
possessing local anesthetic properties, came a wave of enthusiastic 
adoption by surgeons of a long-sought ideal. In its wake, as 
promptly, came disasters and disappointments. Seeking still 
further, innumerable substitutes were found and lauded—still with 
similar results. Why there have been so many failures dimming 
the glory of each new remedy, so much misgiving in the surgical 
and the lay mind, has never been so clearly presented and con¬ 
cisely explained as in this book, the result of twenty years’ study 
and work, concentrated on the solution of this problem. 

Induction of local anesthesia in any given area involves ana¬ 
tomical, surgical and psychic factors which in the past were 
ignored, overlooked or unthought of by the novice, and which 
account for the frequent early failures! 

However, the problem has been studied from every conceivable 
angle, and every beneficial influence has been utilized by Dr. 
Farr, so that his success has been phenomenal and most grati¬ 
fying; and may be duplicated by anyone willing to profit by his 
experiences. 

With every aspect of the specific problem studied and logically 
weighed, conclusions have been reached that, while convincing, 
are presented in a refreshingly modest manner. 

His many personally devised improvements in instruments, 
technic and accessory aids have been by him lightly passed over; 
his wonderfully systematized approach to his final demonstration 
that Local Anesthesia now rests upon a fixed and solid foundation 
is confirmed by his presentation of actual clinical case histories, 
fully illustrated, for every part of the body, even the brain. 

Lewis L. McArthur. 

Chicago, 1923. 







CONTENTS. 


PART I. 


ANESTHETICS, AND THEIR PROBLEM—EQUIPMENT- 
TECHNIC—ANATOMY OF THE SENSORY NER¬ 
VOUS SYSTEM. 


CHAPTER I. 


The General Anesthetics. 

Toxicity and Ill Effects.18 

Effects on the General System.18 

Effects on Special Organs and Tissues.21 

Gangrenous Pneumonia and Lung Abscess.22 

Ether.24 

Ethanesal.25 

Chloroform. 2G 

Nitrous oxide.28 

The Dangers of General Anesthesia.29 

Mortality of the General Anesthetics.31 


CHAPTER II. 


The Local Anesthetics. 

Methods of Producing Local Anesthesia.33 

Cold ..33 

Pressure.34 

Phenol.34 

Cocain.35 

Beta-eucain.35 

Tropacocain.36 

Stovain.37 

Alypin.38 

Apothesin.38 

Allocain-S.39 

Nirvanin.39 

Quinin and Lrea Hydrochloride.40 

Benzyl Alcohol.41 

Benzylcarbinol.42 

Saligenin (Salicain).42 

Butyn.43 

Epinephnn.44 

Novocain (Procain) . 45 

Acidosis Research upon Patients after Using Local Anesthesia ... 48 

Relative Desirable Properties of Local Anesthetics.52 

CHAPTER HI. 

The Anesthesia Problem. 

The Patient’s Interests.55 

The Choice of an Anesthetic.55 

Safety.56 

Efficiency.56 

Comfort.58 

































X 


CONTENTS 


Some Special Advantages of Local Anesthesia During Operation . . 61 

Advantages Before and After Operation.63 

The Attitude of the Patient in Relation to Local Anesthesia and Upon 

What it Depends.64 

General Intelligence of the Patient.66 

The Psychic Aspect of a Surgical Case.. 66 

The Question of Discussing the Form of Anesthesia with the Patient 68 
The Necessity of Attention to Psychic Aspects by Attendants . . 69 

“Psychic Shock,”.70 

Preliminary Narcotics.72 

Narco-local Anesthesia.72 

The Hospital in Relation to the Anesthesia Problem.74 

Medical Teaching in Relation to Local Anesthesia.74 

The General Practitioner in Relation to Local Anesthesia.75 

The Nurse versus the Physician Anesthetist.76 

The Surgeon His Own Anesthetist.77 

The Progress of Local Anesthesia and Upon What It Depends ... 78 

Mixed Anesthesia.78 

Psycho-local Anesthesia. 79 

Operating by Fractional Method.80 


CHAPTER IV. 

Equipment and Armamentarium. 


Necessity for Special Equipment.82 

The Operating Table.83 

Tilting.84 

Syringes . 85 

Needles for Infiltration.86 

The Pneumatic Injector.; 88 

Detailed Description of the Pneumatic Injector.92 

Other Uses for the Pneumatic Injector Pneumoperitoneum ... 95 

Operating Room Lighting.95 

The Elephant Trunk Lamp.97 

The Automatic Wire-spring Retractor.97 

The Automatic Lifter.101 

Description of the Automatic Lifter.103 

The Goiter Clamp.104 

The Prostatic Retractor.106 

The Viscera Retainer.106 


CHAPTER V. 
General Technic. 


The Principles of the Application of Local Anesthesia to Surgery . . Ill 

A Definition of the Terms Employed.Ill 

Infiltration Anesthesia.Ill 

Regional or Conduction Anesthesia.Ill 

Infiltration Block.112 

Venous Anesthesia.112 

Arterial Anesthesia. 114 

Sacral Anesthesia. 115 

Parasacral Anesthesia. 119 

Trans-sacral Anesthesia . 121 

Paravertebral Anesthesia.122 

Splanchnic Anesthesia.124 

Posterior (Kappis). 124 

Anterior Splanchnic Anesthesia (Kappis and Author’s) . . . . 125 

Handling the Abdominal Viscera.129 

Brachial Anesthesia ........ 129 

Narco-local Anesthesia.132 

















































CONTENTS 


xi 


Synergistic Anesthesia.133 

The Preparation of a Patient for an Operation Under Local Anesthesia . 135 

Psychic.135 

The Application of Regional Anesthesia.136 

Direct Infiltration versus Regional Anesthesia.137 

Desirability of Simplifying the Technic of Local Anesthesia and Some 

Advantages of Infiltration Anesthesia.139 

The Choice of Methods of Administering Local Anesthesia . . . . 143 

Infiltration Anesthesia Technic.144 

Some of the Causes of Failure of Local Anesthesia in Abdominal Surgery 147 
General Considerations Regarding the Induction of Local Anesthesia 
after the Time has Arrived for the Giving of the Anesthetic . . . 148 

The Introduction of the Anesthetic Solution.149 

Technic.149 

The Initial Wheal.149 

Anesthetization of the Skin Line.149 

Intradermal Method. 149 

The Author’s Subdermal Method.150 

The Painless Secondary Intradermal Wheal.150 

The Technic of Deep Layer Infiltration.151 

Safety of Deep Infiltration.152 

The Technic of Skin Incision and Opening the Abdominal 

Cavity.153 

Surgical Technic and Some of the Adjuncts Demanded by Local Anesthesia 154 

Sponging.154 

Tying of Ligatures.154 

Forceps Tie (Grant).156 

The Three-forceps Tie (Author’s).156 

The Four-forceps Tie (Author’s).156 

The Gauze Retractor.156 

Operating Room Deportment.159 

The Psycho-anesthetist.160 

Surgical Strategy. .161 

Music.162 

Miscellaneous.162 

Hypodermoclysis (Bartlett).162 

Skin-grafting—Thiersch’s Method.163 

Preparation of Field for Application of Graft . . .163 

Preparation of Field for Removal of Graft.164 

Pedicle Flaps and Wolff Grafts.164 

CHAPTER VI. 

The Anatomy of the Sensory Nervous System. 

Nerves of the Head and Face.166 

The Trigeminal Nerve.166 

The Ophthalmic Nerve.166 

The Lacrimal Nerve.166 

The Frontal Nerve.166 

The Nasociliary Nerve.167 

The Maxillary Nerve.167 

The Zygomatic Nerve.167 

The Mandibular Nerve and Branches.168 

The Lingual Nerve.169 

The Inferior Alveolar Nerve.169 

The Facial Nerve.169 

The Glossopharyngeal Nerve.169 

The Vagus Nerve.169 

The Spinal Nerves.170 

The Cervical Nerves.170 

The Cervical Plexus.170 

The Brachial Plexus.172 

The Thoracic Nerves.173 









































xii CONTENTS 

The Lumbosacral Plexus. 175 

The Lumbar Nerves.175 

The Iliohypogastric Nerve.175 

The Ilioinguinal Nerve.176 

The Genitofemoral Nerve.176 

The Lateral Femoral Cutaneous Nerve.176 

The Obturator Nerve.177 

The Accessory Obturator Nerve.177 

The Femoral Nerve.177 

The Saphenous Nerve.177 

The Sacral and Coccygeal Nerves.178 

The Posterior Femoral Cutaneous Nerve.178 

The Sciatic Nerve.178 

The Tibial Nerve.179 

The Common Peroneal Nerve.180 

The Pudendal Plexus and Branches.181 

The Perforating Cutaneous Nerve.182 

The Pudendal Nerve.182 

The Inferior Hemorrhoidal Nerve ..182 

The Perineal Nerve.182 

The Dorsal Nerve of the Penis.182 

The Visceral Branches.182 

The Muscular Branches.182 

Anococcygeal Nerves.182 

The Sympathetic Nervous System.182 

The Celiac Plexus.183 


PART II. 

LOCAL ANESTHESIA IN SURGERY OF ALL REGIONS OF 
THE BODY EXCEPT THE ABDOMEN. 

CHAPTER VII. 

Local Anesthesia in Surgery of the Head and Face. 

The Nerve Supply of the Scalp.185 

Anesthesia of the Scalp.186 

Duration.189 

Excision of New Growths.190 

Atheromata.190 

Surgery of the Skull.190 

Fractures of the Vault of the Skull.190 

Operations Upon the Brain.191 

Subtemporal Decompression.193 

The Ear and Mastoid.194 

Anesthesia of the Tympanic Cavity.194 

The Nerve Supply of the Face.197 

Surgery of the Face.197 

Anesthesia.198 

Blocking of the Trigeminus Nerve.198 

The Ophthalmic Nerve.198 

The Maxillary Nerve.200 

The Mandibular Nerve.202 

Skin Plastics. 220 

Hare-lip.220 































CONTENTS xiii 

Surgery of the Mouth and Throat.222 

The Tonsils.222 

Tonsillectomy.222 

Infiltration.222 

Surgery of the Tongue.224 

The Palate.226 

CHAPTER VIII. 

Local Anesthesia in Surgery of the Neck. 

General Considerations.229 

Advantages.229 

Cooperation of the Patient.229 

Nerve Supply of the Neck.229 

Methods of Inducing Anesthesia.230 

Deep Cervical Infiltration.230 

Tuberculous Glands and Malignant Disease.232 

The Thyroid.237 

Thyroidectomy in Non-toxic Cases.237 

Anesthetic and Surgical Technic.237 

Toxic Thyroids.243 

Ligation of the Thyroid Arteries.243 

Thyroidectomy in Toxic Cases.243 

The Larynx.246 

Nerve Supply of the Larynx.246 

Laryngectomy.246 

Technic of Anesthesia.246 

CHAPTER IX. 

Local Anesthesia in Surgery of the Breast, Thorax and Spine. 

Surgery of the Breast.251 

Benign Tumors—Frozen Sections. 251 

Technic of Anesthesia.251 

Suppurative Mastitis.254 

Technic of Anesthesia for Drainage.254 

Malignant Tumors.254 

Excision of the Breast.254 

Radical Excision.256 

Surgery of the Thorax.261 

The Thoracic Nerves.261 

Thoracentesis.262 

Anesthesia Technic.262 

Costectomy.263 

Technic of Anesthesia.263 

Empyema.264 

Negative Pressure.264 

Massive Rib Resections.264 

Surgery of the Spine.267 

Technic of Anesthesia.268 

CHAPTER X. 

Local Anesthesia in Surgery of the Extremities. 

General Considerations . . . 271 

Application of Local Anesthesia to Fluoroscopic and Radioscopic 

Examination.271 

Local Anesthesia of the Hands and Feet.271 

Local Anesthesia of the Fingers and Toes.272 

Transverse Infiltration Block.275 










































XIV 


CONTENTS 


The Reduction of Fractures and Dislocations . . 276 

The Reduction of Fractures and Dislocations in Children . . . 278 

The Reduction of Malunited Fractures in Children.281 

Bone Transplants.283 

Technic of Anesthesia.283 

Amputations.286 

Technic of Anesthesia.286 

The Upper Extremities.286 

The Lower Extremities.287 

Suppurative Arthritis ..289 

Technic of Anesthesia for Drainage.289 

Osteomyelitis.290 

Acute Osteomyelitis.290 

Technic of Anesthesia for Drainage.290 

Chronic Osteomyelitis.290 

Choice of Methods of Producing Local Anesthesia in the Upper Extremities 291 

Surgery of the Shoulder and Clavicle.291 

Nerve Supply of the Shoulder and Clavicular Region.291 

Technic of Anesthesia.292 

Brachial Anesthesia.292 

Surgery of the Elbow-joint.294 

Arthroplasty.294 

Surgery of the Wrist.297 

Nerve Supply of the Wrist.297 

Surgery of the Hip.297 

Nerve Supply of the Lower Extremity to the Region of the Hip-joint 297 

Open Operation.298 

Technic of Anesthesia.298 

Fractures and Dislocations..299 

Technic of Anesthesia.299 

Arthroplasty of the Hip.302 

Fracture of the Femur.302 

Closed Operation.302 

Technic of Anesthesia.302 

Open Operation.303 

Technic of Anesthesia.303 

The Knee-joint. 305 

The Nerve Supply.305 

Technic of Anesthesia.306 

Fracture of the Patella.307 

Technic of Anesthesia.307 

Floating Cartilages.307 

The Leg. 308 

Fractures, Closed Operations.308 

Surgery of the Ankle-joint.310 

Nerve Supply.310 

Special Fractures.310 

Pott’s Fracture.310 

The Cadivilla Pin.311 

Hallux Valgus (Bunions).311 

Technic of Anesthesia. 311 

Varicose Veins of the Leg. . 312 

CHAPTER XI. 

Local Anesthesia in Surgery of the Genito-urinary System. 

Anesthesia and Genito-urinary Surgery.315 

Local Anesthesia in Surgery of the Kidneys.316 

Nerve Supply. 316 

Technic of Anesthesia , .. 317 




















































CONTENTS XV 

Local Anesthesia in Surgery of the Kidneys—• 

The Kidney. 319 

Sensation. 319 

Incision. 319 

Delivery of the Kidney.321 

The Ureter.323 

Calculi ..323 

Technic.324 

Grave Surgical Problems.325 

The Bladder.328 

Cystoscopy.328 

Suprapubic Cystotomy.329 

Method of Opening Bladder.329 

Local Anesthesia in Suprapubic Prostatectomy.331 

Sacral Anesthesia.331 

Technic of Infiltration.331 

Prostatic Retractor.332 

Perineal Prostatectomy. Abscess.338 

The Male Urethra.338 

Stricture.338 

The Penis.340 

Nerve Supply.340 

Circumcision.341 

Amputation of the Penis for Malignant Disease.341 

Hypospadias.341 

Varicocele.341 

Skin Sterilization.341 

Technic of Infiltration.342 

Hydrocele—Orchidectomy—Vasectomy.342 

Technic of Infiltration.343 

Vasotomy.344 

The Female Genitalia (External).344 

Nerve Supply.344 

General Considerations.345 

Methods of Obtaining Anesthesia.345 

Psychic Considerations.346 

Vaginal Examinations in Virgins.348 

Operations upon the Labia—Cysts—Neoplasms—Abscesses . . . 348 

The Nerve Supply.348 

Technic of Anesthesia.348 

Operations upon the Clitoris.349 

The Nerve Supply.349 

Operations upon the Perineum.349 

The Nerve Supply of the Perineum.349 

Perineorrhaphy.349 

Technic of Anesthesia.349 

Operations upon the Cervix and Uterus—Curettage.352 

The Nerve Supply.352 

Technic of Anesthesia.352 

Anterior Colporrhaphy.354 

Technic of Anesthesia.354 

The Uterus.354 

Interposition Operation.354 

Infiltration Block.354 

Anesthesia.354 

Vaginal Hysterectomy.356 

Technic of Anesthesia.356 

Miscellaneous Operations.357 

Atresia of the Hymen.357 

Artificial Vagina.358 

Pelvic Abscess in Women ..360 


























































XVI 


CONTENTS 


CHAPTER XII. 


Local Anesthesia in Surgery of the Rectum and Anus. 


Surgery of the Rectum and Anus ..362 

Preparation of the Patient.362 

Choice of Local Anesthetic Methods.362 

Nerve Supply of this Region.363 

Technic of Circumferential Infiltration.363 

Sphincter Divulsion.366 

Rectal Examination.368 

Hemorrhoids, Ulcers, Fissures and Polypi.369 

Fistula-in-Ano.369 

Infiltration Block.370 

Carcinoma of the Rectum.373 

Prolapse of the Rectum.373 

Postoperative Comfort.377 

Quinin and Urea Hydrochloride ..377 


PART III. 

LOCAL ANESTHESIA IN SURGERY OF THE ABDOMINAL 

WALL AND CAVITY. 

CHAPTER XIII. 


Local Anesthesia in Surgery of the Abdomen. 


General Considerations.. . . 379 

Intraperitoneal Pain Sense.379 

Position of the Patient.384 

Retraction.385 

Direction, Site and Choice of Incisions. 385 

The Resultant Scar.387 

Relative Importance of the Division of the Muscular as Com¬ 
pared with Aponeurotic Tissue.388 

Conservation of the Blood Supply.389 

Conservation of the Nerve Supply.389 

Anticipated Pathology.390 

Facility with Which Incisions May be Made and Closed . . 390 

The Relaxation Afforded During and After Operation . . . 391 

Technic.391 

Closure. 394 

The Making of the Incision. 397 

Technic. 397 

Muscular Relaxation.398 

Duties of the Psycho-anesthetist.398 

Abdominal Exploration. 399 

The Examination of the Abdominal Organs.400 

Viscero-parietal Adhesions ..401 

































CONTENTS xvii 


CHAPTER XIV. 

Local Anesthesia in Surgery of the Abdominal Wall (Hernia). 

Hernia.402 

Inguinal Hernia.402 

Nerve Supply.402 

Skin Sterilization.403 

The Induction of Local Anesthesia.403 

Femoral Hernia.406 

Incisional Hernia.406 

Transplantation of Fascia.407 

Epigastric Hernia.411 

Umbilical Hernia and Lipectomy.411 

Strangulated Hernia.415 

CHAPTER XV. 

Local Anesthesia in Surgery of the Upper Abdomen. 

Position of the Patient upon the Operating Table.419 

The Stomach.419 

Avoidance of Clamps.420 

Gastroenterostomy (Anterior).420 

Gastroenterostomy (Posterior).421 

Ulcers.423 

Perforated Gastric and Duodenal Ulcers—Acute and Chronic 423 

Sleeve Resection.427 

Neoplasms (Malignant).428 

Resection for Carcinoma.428 

Hypertrophic Pyloric Stenosis.430 

The Liver.438 

Cysts, Abscess and Rupture.438 

Gall-bladder and Ducts.440 

Technic of Anesthesia.440 

Opening of Abdominal Cavity.441 

Cholecystostomy.441 

Sensation of the Gall-bladder.441 

Cholecystectomy.441 

Exposure.441 

Anterior Splanchnic Anesthesia.443 

Technic of Exposing the Gall-bladder.446 

The Method of Removing the Gall-bladder.446 

Bile Ducts.453 

Choledochotomy.453 

The Pancreas.457 

The Spleen.458 

CHAPTER XVI. 

Local Anesthesia in Surgery of the Intestines. 

Special Considerations.459 

Diagnosis.459 

Treatment of Simple Conditions.459 

Treatment of Complicated Conditions.460 

Resection for Cancer.460 

Colostomy.463 

Technic of Operation.463 

Intussusception.463 













































XV111 


CONTENTS 


Intussusception in Children.465 

Tuberculous Peritonitis.466 

Intestinal Obstruction from Other Causes.468 

Technic of Temporary Drainage of Distended Bowel.469 

The Rubber Towel Method (Author’s).469 

Enterostomy.470 

Peritonitis Ileus.470 

CHAPTER XVII. 

Local Anesthesia in Surgery of the Appendix. 

Appendicitis.471 

Special Considerations.471 

Acute or Subacute.471 

Medical Management.471 

Surgical Management.471 

Preoperative Management.471 

Operative Management. 471 

Effect of Anesthesia upon Postoperative Course . . . . 472 

Position upon the Operating Table.472 

Incisions.472 

Chronic Appendicitis.472 

The Transverse Abdominal Incision.473 

Technic of Subdermal Infiltration.476 

Technic of Deep Infiltration.476 

Technic of Opening the Abdomen.478 

Technic of Meso-appendix Infiltration.478 

Technic of Delivering Appendix.479 

Appendicectomy under Varying Conditions.480 

Acute Appendicitis.480 

Abdominal Infiltration and Muscular Relaxation.481 

Technic of Delivering Acute Appendix.482 

Intra-abdominal Abscess.. . 484 

Technic for Drainage.484 

Superficial Abscess.486 

Technic for Drainage.486 

The Appendix and Pelvis.487 

Special Considerations.487 

Position upon Operating Table.488 

CHAPTER XVIII. 

Local Anesthesia in Surgery of the Pelvis. 

Pelvic Blocking.489 

Skin Sterilization :.489 

Incisions for Pelvic Operations.489 

Exposure.489 

Adjuncts to Pelvic Operations.492 

Technic of Intra-abdominal Pelvic Infiltration and Blocking .... 494 

Anterior Splanchnic Anesthesia. 494 

The Uterus. 495 

Hysteropexy.. 495 

Myomectomy. 499 

Abdominal Hysterectomy. 497 

Panhysterectomy. 498 

Fallopian Tubes. 500 

Cesarean Section.502 

The Ovary . .. . .... 503 

Postoperative Drainage.507 



















































PRACTICAL LOCAL ANESTHESIA 


PART I. 

ANESTHETICS-EQUIPMENT-TECHNIC-ANATOMY 
OF THE SENSORY NERVOUS SYSTEM. 


CHAPTER I. 

THE GENERAL ANESTHETICS. 

As time goes on new discoveries are found in the various sciences, 
many of which are epoch making. Certainly the discovery of 
general anesthesia is such. It has filled a great need in the advance¬ 
ment of surgery and will continue to do so. Notwithstanding this 
fact its use is accompanied by dangers and its unsatisfactory admin¬ 
istration is not an infrequent occurrence. The pathology in the 
case, the ability of the anesthetist, and other circumstances all 
have an important bearing on the outcome. 

Many of the profession fail as yet to see the great value and 
true scope of local anesthesia in general surgery. It has been 
frequently exemplified in the history of medicine that a large 
proportion of the medical profession holds back and refuses to 
accept big truths when they are presented. The application of 
these truths may even meet and relieve unsatisfactory conditions 
and yet they will excite prejudice and be attacked by many con¬ 
servative physicians. 

The conservative attitude of the medical profession in regard 
to the question of local anesthesia may be clearly noted by con¬ 
trasting it with the attitude of the dental profession. It is difficult 
to demonstrate any great degree of excellence of local over general 
anesthesia in dentistry that does not apply to general surgery as 
well. However, the individual members of the dental profession 
have considered no effort too great to acquire a knowledge of its 
use and to overcome the technical difficulties connected with its 
2 




18 


THE GENERAL ANESTHETICS, 


administration; and they have adopted it almost universally, 
with untold benefit to their clientele. The teachers and moulders 
of thought in the dental profession have been careful to see that 
their pupils were given the advantages offered by the newer dis¬ 
coveries of the application of local anesthesia, while it must be 
admitted that the conservatism of the medical profession has not 
operated to the equal advantage of their patients. 

In the following discussion of the general anesthetics the ill 
effects, dangers and discomforts of each will be considered, as it 
is only by the elimination of these, the undesirable features, that 
progress is made in considering substitutes. 

TOXICITY AND ILL EFFECTS. 

Effects on the General System.— Authorities agree at present 
that the general anesthetics produce an acidosis in the body, the 
degree of which varies with the anesthetic used, the duration of 
anesthesia, and the previous general condition of the patient. 
In speaking of conditions other than diabetes that are characterized 
by an acid intoxication, H. G. Wells 1 states, “Most prominent 
of these so-called acid intoxications is that following a few days 
after anesthesia, particularly with chloroform.” 

It has been shown, especially by Brewer and by Helen Baldwin 2 
that acetone is nearly always present in the urine during the first 
twenty-four hours after the administration of either chloroform 
or ether, and occasionally diacetic acid appears on the second or 
third day after. Ross , 3 who reports some observations on the 
occurrence of acidosis following operation, brings out the importance 
of proper interpretation of urinalyses. Many of her patients 
excreted diacetic acid and acetone but gave none of the symptoms 
of acidosis, namely, nausea, vomiting, headache, restlessness or 
in severe form with deepening coma, fever, tachycardia, hyperpnea 
or death. Others who did not show acetone or diacetic acid in 
the urine did have symptoms and thus the urinalysis is of value 
only when elimination parallels acid body formation. When all 
the acid bodies formed are excreted they do not encroach upon 
the alkali reserve of the blood and thus determination of blood 
carbon dioxide (Van Slyke) would seem to be a preferable guide. 
But even this is not thought by some to be as accurate as the 
determination of the Id-ion concentration of the blood (Crile), 
which has been shown to be reduced immediately after ether or 
nitrous oxide are given. 

1 Chemical Pathology, p. 457. 2 Jour, of Biol. Chem., 1906, 1, 239. 

3 Some Observations on the Occurrence of Acidosis Following Operation, Am. 
Jour. Surg., Anes. Supp., October, 1921, 35, 121. 


TOXICITY AND ILL EFFECTS 


19 


Ross further found that the symptoms of acidosis were much 
less marked in cases having had local anesthesia and that ether 
anesthesia resulted in more marked symptoms than where nitrous 
oxide and oxygen were used. The urinary findings were not per¬ 
fect with local anesthetics but showed less evidence of acidosis 
than did the cases which had had ether or nitrous oxide and which 
showed about an ecpial number of acid bodies. Some of the most 
severe cases of acidosis were those having had a general anesthetic 
for but a short time as in the removal of tonsils and adenoids and 
she concludes that the length of time for the operation or anesthetic 
is not an important factor. However, toxemia, starvation and 
fear were shown to increase the acid bodies of the urine. 

E. Graham 1 2 states: “The phenomenon of narcosis is always 
accompanied by a condition of diminished oxidation. It there¬ 
fore always indicates a condition of more or less severe asphyxia 
of the tissues, even if the frequency and depth of the respirations 
of the narcotized subject are normal.” 

Ross advocates ether colonic anesthesia to eliminate suboxy¬ 
genation as well as fear. 

J. Loeb 5 has shown that an asphyxiated tissue always becomes 
acid. It is not surprising, therefore, that every surgical general 
anesthesia induces many of the signs of an acid intoxication. As 
is well known also, an existing acidosis is always aggravated by 
general anesthesia. He further states that ether and nitrous 
oxide cause these toxic effects less readily than does chloroform, 
because of the formation of the mineral (hydrochloric) acid when 
the latter is used. 

McClendon 3 in an experimental study on the effects of anesthetics 
(ether, chloroform, chloretone and alcohol) on cells of a marine 
jelly fish (Cassiopea) found that respiration was not depressed 
nor were the cells affected by ether in concentration sufficient to 
abolish nerve and muscle activity. Only when stimuli causing 
muscular contraction were applied was respiration depressed, and 
this due to carbon dioxide, but not due to the acidity of carbonic 
acid. In addition he found that the anesthetic caused an increase 
in the diffusion of salts away from the cells, in some cases ten 
times and with death resulting. He therefore suggests that because 
substances leave the cells more rapidly when anesthetized there 
is a real danger from an overdose. 

Crile 4 likewise has shown that the nerve cells exhibit a disinte- 


1 Jour. Am. Med. Assn., November 17, 1917, p. 1666. 

2 From Article by E. Graham, Jour. Am. Med. Assn., November 17, 1917, p. 1666. 

3 Effects of Anesthetics on Cells, Am. Jour. Surg., Anes. Supp., October, 1921, 
35, 104. 

4 Crile and Lower: “Shock,” 1921. 


20 


THE GENERAL ANESTHETICS 


gration and fading of the Nissl bodies during general anesthesia 
with ether. 

Jeanbrau, Cristol and Bonnet , 1 in a limited number of cases 
report that acidosis occurred in all cases with various forms of 
anesthesia, except with spinal, using procain (syncain). 

Normally the blood carries the carbon dioxide away from the 
tissues to the lungs in combination with its alkalies. The most 
important and most abundant alkali is sodium bicarbonate which 
in the lungs is decomposed into the carbonate, and carbon dioxide 
which escapes into the alveolar air. The carbonate thus formed 
goes back to the tissues where it combines with more carbon 
dioxide. The acids, when introduced into the blood during 
anesthesia, combine with these alkalies forming neutral salts 
which are eliminated in the urine, and in this way the amount 
of alkali in the blood is reduced, with a consequent reduction in 
the capacity of the blood to carry carbon dioxide away from 
the tissues. Consequently, in general anesthesia the carbon 
dioxide produced in metabolism accumulates in the tissues 
where it is formed, and blocks the processes of oxidation, so that 
the patient suffers from asphyxia exactly as if he were deprived 
of air. 

Some patients are, of course, more susceptible to the production 
of acids in the blood by the administration of general anesthesia 
than are others because of the presence of such conditions as dia¬ 
betes, certain febrile diseases, carcinoma, gastro-enteritis, certain 
nervous diseases, inanition, and toxemias from septic absorption, 
in all of which there is already a varying degree of acid intoxication. 
Hence a general anesthetic in these conditions tends to augment 
the pathological processes and to weaken the patient’s defense 
against them and therefore to raise the mortality of the operative 
procedures. 

Postoperative shock is another general condition which bears 
a definite relationship to general anesthesia. The two are inti¬ 
mately associated. To what degree the general anesthetics con¬ 
tribute directly to the causation of shock seems to be still an open 
question. 

F. C. Mann 2 states: “Deep etherization may produce most of 
the symptoms of shock. The continued depressed state following 
deep anesthesia, while primarily due to the anesthetic, is soon 
complicated by the resulting factors of low blood-pressure, sub¬ 
normal temperature, and other changes.” 

It is most likely true that postoperative shock is produced by 

1 Anesthesia Acidosis, Abstract Jour. Am. Med, Assn., August, 1921, 77 , 652, 

? Jour. Ain. Med, Assn., 1917, 69 , 371-374, 


EFFECTS ON SPECIAL ORGANS AND TISSUES 


21 


several combined contributory factors, the relative importance 
of each varying in different individuals. But these factors, such 
as hemorrhage, mechanical trauma to the viscera and other tissues, 
are undoubtedly of greater importance in general anesthesia because 
the unconscious condition of the patient frequently permits of 
their unnecessary occurrence and on account of other reasons which 
will be referred to later more in detail. 


EFFECTS ON SPECIAL ORGANS AND TISSUES. 

In considering the effects of the general anesthetic substance 
on the special or separate organs in the body, each anesthetic will 
be considered individually. It is not the purpose of the author 
to dwell at great length on this subject as the toxic effects of ether 
and chloroform particularly are quite widely taught and known. 

It is generally conceded by the leading anesthetists that the 
open method of etherization is the safest. The ether-vapor rectal 
anesthesia, ether-oil colonic anesthesia, and intravenous methods 
have been tried and with some success but they may have suf¬ 
ficient objections and dangers to outweigh their few advantages. 
The open method is perhaps the best method because the patient 
receives a larger amount of oxygen in the inspired air, and it is 
by far the most commonly used of all the methods. The fact 
that this method is the safest does not mean that it has not its 
dangers. Its safety depends to a great extent upon the anesthetist 
as it is not difficult to give an overdose of the drug. Ether, further¬ 
more, does not lose its toxic properties when given by this method, 
although its toxicity perhaps may be reduced somewhat. 

The first effect of ether, on being inhaled, is upon the respira¬ 
tory passages. It is a powerful stimulant to these organs, increasing 
the respiratory rate during the early stages. When given by the 
open method the inspired air will be twenty to thirty degrees 
cooler than the air of the room. Because ether is irritating, the 
mucous membranes of the mouth, pharynx and larynx become 
swollen, an increased amount of mucus and saliva are secreted, 
and this is drawn down by the deeper inspirations into the depths 
of the lung and even into the alveoli, especially when sufficiently 
deep to abolish the reflexes of the respiratory system. The bron¬ 
chial tree itself becomes chilled, the epithelial lining becomes con¬ 
gested and often petechial hemorrhages are found in the bron¬ 
chioles and alveoli. Every prolonged ether narcosis is followed 
by small pneumonic foci in the lungs with mucus and extravasated 
blood cells in the alveoli, and some round-cell infiltration. This 


22 


THE GENERAL ANESTHETICS 


may occur after a shorter operation in the predisposed or suscepti¬ 
ble . 1 Thus is laid the foundation for a subsequent pulmonary 
edema or a postoperative bronchitis or pneumonia. 

Gangrenous Pneumonia and Lung Abscess.—One sees from time 
to time in literature statements indicating that lung complications 
are not more common following general anesthesia than when local 
anesthesia has been employed. In these articles various authorities 
are quoted and the experience of certain individuals is detailed. As 
a rule these observations are made upon groups of patients that 
are the recipients of the utmost care during the administration of 
general anesthesia. 

Incidentally it might be said that in many of these reports a com¬ 
parison is made between the effects of local and general anesthesia 
by those who are observers upon the same series of cases. In most 
instances it will be found that local anesthesia has been reserved 
for the cases that carry the greatest hazard and which, therefore, 
are, or should be, most susceptible to lung complications. While 
pneumonia is in a certain percentage of cases of undoubted embolic 
origin and while surgery of the upper abdomen is all too frequently 
followed by pneumonia, even when local anesthesia is used, it 
stands to reason that, other things being equal, the lung which 
contains foreign material aspirated during operation under general 
anesthesia must be less able to cope with such embolic processes 
and with the other etiological factors which are potentially present 
in every surgical case. 

The individual who is under general anesthesia presents at 
least a lowered irritability of the tracheal reflexes. With a care- 
less anesthetist these reflexes may be quite completely abolished. 
Undoubtedly the natural protection offered the pulmonary system 
by these reflexes has its threshold of safety lowered during the 
inhalation of general anesthesia. 

H. E. Robertson 2 has been able to demonstrate the presence of 
gastric contents in the center of localized lung abscesses in cases 
which came to autopsy. Were this condition looked for more 
frequently its presence would undoubtedly be demonstrated. 

It seems to us that it is perfectly obvious that lung complications, 
aside from embolic (and even here local conditions after general 
anesthesia are more favorable for the development of the embolic 
processes) are more prone to follow the administration of general 
than local anesthesia. 

It requires a long series of observations to establish clinical 
facts, and it will undoubtedly require considerable time to demon- 

1 Dickinson, G. K.: Am. Jour. Surg., January, 1918, p. 24. 

2 Personal Communication. 



GANGRENOUS PNEUMONIA AND LUNG ABSCESS 


23 


strate the truth or fallacy of this premise. The facts will, per¬ 
haps, not be demonstrated with satisfaction until such time as 
observers are able to compare local and general anesthesia in a 
large series of cases in which each is administered with equal 
skill. 


Incidentally, it should be most definitely understood that the 
terms employed should be made as significant as possible, to-wit: 
Any patient receiving any amount of general anesthesia should 
not be classed with operations done under local anesthesia. In 
reaching conclusions, therefore, the methods should be strictly 
classified under general anesthesia, local anesthesia and mixed 
anesthesia. 

The local irritation of ether may explain in part the vomiting 
which is so often a prominent feature of its administration. The 
irritant vapors reach not only the throat, but also the stomach 
with the mucus swallowed, and the irritation in both of these 
regions may cause reflex vomiting. There is probably some central 
effect also in the production of vomiting, as this undesirable effect 
is occasionally caused by nitrous oxide, in which local irritation 
plays no part. 

Reimann 1 states that he found the more excessive nausea and 
vomiting in those cases which showed the greater degrees of acidosis, 
and this would tend to bear out a theory of central stimulation of 
the vomiting center. Caldwell and Cleveland 2 found a reduction 
of blood carbon dioxide of 12 to 14 per cent with the various 
anesthetics and claim that the difference between local and general 
anesthesia is negligible and that the postoperative course is not 
affected by the preliminary administration of sodium bicarbonate. 
This would tend to disprove such a theory for they also found 
that nitrous oxide and oxygen inhalation produced less nausea and 
vomiting than the other inhalants, yet the carbon dioxide of the 
blood was diminished fully as much as with ether. 

Truly enough there are so many other factors such as infection 3 
endocrine disturbance 4 diet and preparation to be considered, 
besides the anesthetics and the laboratory reading and interpretation 
of the Van Slyke method that one cannot help giving the clinical 
symptoms just consideration. The question, “ Does less nausea and 


1 Administration of Carbon Dioxide after Anesthesia and Operation, Jour. Am. 
Med. Assn., February 12, 1921, 76 , 437. 

2 Surg., Gynec. and Obst., 1917, 25 , 23. 

3 Hirsch, E. F.: Changes in Leukocytes and Alkali Reserve of Blood in Experi¬ 
mental Infections, Jour. Infec. Dis., March, 1921, 28 , 1275. 

4 Underhill, F. P., Nellans, C. T.: The Influence of Thyroparathyroidectomy 
upon Blood-sugar Content and Alkali Reserve, Jour. Biol. Chem., October, 1921, 48 , 
557. 


24 


THE GENERAL ANESTHETICS 


vomiting prevail after local anesthesia as compared to general,” 
is in the large percentage of cases answered in the affirmative. 

Ether.—The kidney seems to he affected in a certain number of 
cases of ether anesthesia, as is shown by the appearance of albumin, 
casts and occasionally red blood cells in the urine, or an increase 
in these substances if already present. Various observers have 
recorded 12 to 39 per cent of cases showing this phenomenon. 1 
The early effect of ether is to increase the secretion of urine. Later 
during full anesthesia the secretion of urine is almost completely 
arrested. On removal of the anesthetic the kidneys rapidly recover 
from this depression, and there is hyperaction lasting for some 
hours. 2 The effect of ether upon the kidneys is merely one mani¬ 
festation of a general intoxication of the system from the drug. 
Degenerations of the parenchymatous organs throughout the body 
have been revealed and these are most prominent in the kidneys. 3 

The action of ether upon the nervous system is similar to that 
of chloroform and of a large amount of alcohol, consisting in a 
progressive paralysis of various centers, frequently, however, 
being preceded by a short stage of stimulation. As the anes¬ 
thesia deepens the centers of consciousness and other brain centers 
become entirely paralyzed, and finally the spinal cord is involved, 
the reflexes disappear and the muscles eventually completely lose 
their tonicity. The respiratory and vasomotor centers, however, 
are not paralyzed until a still larger quantity of the drug has been 
used. The art of administering anesthesia consists in avoiding 
as far as possible encroachment of the ill effects of the drug upon 
these last mentioned centers. 

The heart rate is increased, often to 90 or 100 per minute, the 
internal vessels are constricted and the blood-pressure is raised 
in spite of a peripheral vasodilatation. Prolonged ether anes¬ 
thesia causes depression of the heart and relaxation of the splanchnic 
circulation. 

Blood destruction takes place during ether anesthesia although 
this is not always apparent because of the concentration of the 
blood due to preliminary treatment and sweating during the 
administration. J. C. Da Costa and J. L. Ivaltever 4 state: “The 
color index almost always falls and the number of corpuscles 
increases, showing marked blood destruction and increased pro¬ 
duction of corpuscles deficient in hemoglobin. . . . The hemo¬ 

globin is absolutely reduced after etherization, as shown by reduc¬ 
tion in individual corpuscular hemoglobin value.” 


1 Goodwin: Therap. Gaz., May, 1905. 

2 Thompson: British Med. Jour., March 25, 1905. 

3 Hirsch, M.: Centralbl. f. d. Grenz. d. Med. Chir., December 31, 190S. 

4 Boston Med. and Surg. Jour., June 13, 1901. 


GANGRENOUS PNEUMONIA AND LUNG ABSCESS 


25 


1 l ]e coagulation time is markedly decreased, most marked from 
the seventh to the tenth days. 1 

t/ 

Conditions which comprise the contraindications of ether anes¬ 
thesia vary according to different authors. But in a consideration 


of the general and local toxic effects of the drug, as briefly given 
above, it would seem that ether is contraindicated in the follow¬ 
ing conditions: 


1. Respiratory disorders comprising all acute affections, especially 
of the lower passages, and chronic disorders such as tuberculosis, 
pulmonary emphysema, so frequently found in the aged, and 
bronchitis with profuse secretions. 

2. Cardiovascular disease accompanied by a high blood-pressure, 
particularly aneurysm and advanced arteriosclerosis; all decom¬ 
pensated hearts whether due to myocardial change or vascular 
disease, and weakened hearts so often found in septic patients 
as well as in alcoholics. 

3. Acute nephritis, chronic parenchymatous nephritis and even 
the arteriosclerotic type are contraindications. 

4. Diabetes mellitus and, finally, pronounced anemias definitely 
contraindicate the use of ether, as does traumatic shock without 
demonstrable hemorrhage. 

Strange as it may seem, ether in itself is not an anesthetizing 
agent but is the vehicle of ketones, aldehydes and mercaptans 
and it is the latter two which are particularly harmful, and the 
first which is responsible for anesthesia. Wallis found that good 
anesthetic ether free of aldehydes and mercaptans when treated 
with finely divided potassium permanganate yielded a pleasant 
smelling residue which proved to contain the ketones so essential 
to the production of a relatively good and safe anesthetic. He 
further found that by treating the ketones with carbon dioxide 
and ethylene and using the middle series, that when mixed with 
pure ether in varying proportions, a loose chemical combination 
resulted which he called Ethanesal, a new general anesthetic. 

Ethanesal was used by Hewer 2 in 500 surgical cases and he reports 
that respiration was not increased as much as with ether, the 
breathing was quieter and more like the chloroform type of breath¬ 
ing and that there was less mucous-membrane irritation, less 
salivation and there were few^er postoperative respiratory com¬ 
plications than after the use of ether; the blood-pressure changed 
less than when ether was used, the pulse pressure remained higher 
and no ill effects were noted in cases with organic heart disease; 
cerebral excitement was less marked and analgesia easily pro- 


1 Hamburg and Ewing: Jour. Am. Med. Assn., November 7, 1908. 

2 A New General Anesthetic: Its Theory and Practice, The Lancet, June 4, 1921, 


2G 


THE GENERAL ANESTHETICS 


duced: Postoperative acidosis was not observed and three diabe¬ 
tics took the anesthetic well; toxic patients also took the anes¬ 
thetic well; vomiting was absent in 48 per cent of cases, occurred 
once before regaining consciousness in 42 per cent and postoperative 
taste and smell of the anesthetic were practically nil. 

Thus in an attempt to secure an anesthetic that will be safer 
than the ether usually used these workers seem to be at least 
partially rewarded and their very efforts to do so testify to the 
fact that the ether generally used is harmful. 

Chloroform.—Ether and chloroform resemble each other closely in 

their general effects, but differ in certain points of importance. 

Cushny 1 states that chloroform is about three to three and a half 
«/ 

times as depressant to the central nervous system as ether, while, on 
the other hand, its action on the heart is at least eight times as great 
as that of ether. As ether has to be given in more concentrated 
form to produce anesthesia it produces more irritation of the air 
passages than does chloroform. The latter produces anesthesia 
with less difficulty and the stage of excitement is less violent 
and prolonged. It splits up into substances, the chlorine bodies, 
which are extremely toxic. The toxic effect of ether is usually 
exerted on the respiratory system, inducing pulmonary edema 
or postoperative pneumonia or upon the renal system, inducing 
nephritis. The deleterious effects of ether frequently occur immedi¬ 
ately after operation while those of chloroform do not manifest 
themselves for several days. 

Chloroform is distinctly a depressant of the circulatory system. 
This action on the vasomotor center, which causes a vasodilatation 
and accumulation of blood in the larger vascular trunks of the 
body, and hence a fall of blood-pressure, is perhaps the primary 
and main cause of death in chloroform anesthesia. An infrequent 
and also different action of the drug is a reflex inhibition of the 
heart by way of the vagus, produced, it is said, by an irritation of 
the endings of the fifth nerve in the nasal mucous membrane, an 
action which has caused death after only a few whiffs of the drug 
have been taken. 

More than twenty-five years ago, Ungar found that prolonged 
or repeated chloroform anesthesia gave rise to fatty degeneration 
of the liver, causing this organ to lose its power of carrying on its 
functions as a detoxicating organ and of fulfilling its role in metab¬ 
olism. Whipple and Sperry 2 have shown by a series of experi¬ 
ments that chloroform narcosis continued for any considerable 
length of time invariably causes central necrosis of the liver in 
animals and that this necrosis, if extreme, will cause death. They 


1 Text-book of Pharmacology. 

2 Johns Hopkins Hosp. Bulletin, September, 1909. 


GANGRENOUS PNEUMONIA AND LUNG ABSCESS 


27 


state: “The essential change is an extreme necrosis and fatty 
degeneration of the liver. There may be numerous ecchymoses 
and hemorrhages into the peritoneum or upper intestinal tract. 
The pancreas may show many areas of fat necroses and ecchy- 
mosis. The kidney and heart may present a moderate grade of 
fatty degeneration.” 

La Rocque 1 in discussing the effects of general anesthetics 
upon the liver by a review of the literature concludes that chloro¬ 
form and ether both produce a cholemia of about the same duration 
and degree. The question as to whether this is caused by poison¬ 
ing of the circulatory red corpuscles with resulting laking, or to 
intoxication of the hepatic cells, or to asphyxia with lessened 
oxidation and acid intoxication is not answered. 

Delayed chloroform poisoning, a condition which is usually 
fatal, comes on from one to six days after the administration of 
the drug. It is characterized clinically by the somewhat sudden 
appearance of irritability, restlessness, fright and moaning and 
even toxic delirium with rapid pulse, nausea and vomiting and 
later stupor, rise in temperature, Cheyne-Stokes breathing, irregu¬ 
lar heart action and death. It is characterized pathologically by 
advanced fatty changes, particularly in the liver, with congestion 
and areas of necrosis in the kidneys and brown atrophy of the 
heart. Many such cases have been reported. Weill and Yignard 2 
state: “The writers have encountered a series of fatalities after 
operations for appendicitis which they ascribe to the injurious 
action of chloroform on the liver. The disturbances developed 
on the first or second day after operation, the patients showing 
signs of extreme and progressive weakness, sometimes accompanied 
by jaundice and blackish vomiting. The patients all succumbed 
in two or three days, and extremely severe lesions were discovered 
in the liver in every instance. The lesions of peritonitis could 
never cause such fulminating toxic accidents, and there were no 
signs of inflammation of the liver, merely a total cellular necrosis 
with the aspect observed in pernicious jaundice.” 

The conditions comprising the special contraindications to 
chloroform anesthesia may be summarized as follows: 

Cardiac and circulatory disorders with the clinical signs of 
feeble heart action, dyspnea and arrhythmia including all acute 
affections of the pericardium, myocardium and endocardium. 

Respiratory disorders which interfere with the free movements 
of respiration and the complete aeration of the blood, as neo¬ 
plasms, inflammatory lesions and emphysema. In this connection 
enlarged bronchial glands and thymus may be mentioned. 


1 Effects of General Anesthetics on the Liver, Bull. No. 19, 
thesia Research Society, February, 1922, p. 1. 

2 Lyon Chir., December, 1908. 


The National Anes- 


28 


THE GENERAL ANESTHETICS 


Renal disorders with albumin and casts in the urine. 

Hepatic disorders as cirrhosis or yellow atrophy. 

Nitrous oxide is claimed by many to be the safest of all the general 
anesthetics and when combined with oxygen, its most dreaded 
effect, asphyxia, may be readily avoided. It is true that this gas 
is the least toxic of the general anesthetics and produces, there¬ 
fore, less histological changes in the various organs. Anesthesia 
is produced by its depressing effects on the brain centers. It 
exerts very little effect on the cardiovascular system directly and 
the respiratory centers, although slightly depressed by the drug 
itself, are stimulated by carbon dioxide if an asphyxial condition 
of the blood occurs. 

Not much could be said, therefore, concerning the toxicity of 
this substance, but in this connection it might be well to consider 
a few of its other phases. 

There are many advocates of this anesthesia for major surgical 
procedures. The margin of safety is small but this fact is not a 
danger, if the anesthetist be an expert. But it is surprising to 
find the comparatively recent increasing number of deaths reported 
occurring during the administration of this anesthetic. And it 
is not only surprising but somewhat astounding to find after 
thorough investigation that not a few surgeons who advocate it 
have failed to report deaths due to it. This in most instances is 
pure neglect as doubtlessly most of its sponsors are actuated only 
by scientific motives. In the chapter on anesthesia in Johnson’s 
Operative Therapeusis. Connell 1 states in regard to nitrous oxide 
oxygen anesthesia that “since the extensive introduction of this 
gas into general surgery, the reported and unreported deaths 
have probably far exceeded those from ether.” J. F. Baldwin 2 
of Columbus who calls it the most dangerous anesthetic has reported 
a number of cases in which death can be definitely attributed to 
the nitrous oxide-oxygen anesthesia and concluded that the death 
rate in that city had been 1 per cent. 

After making a careful test with one hundred successive cases 
of nitrous-oxide anesthesia, compared with a similar number of 
ether anesthesias by the drop method, Ochsner 3 says he “found 
no difference in the course of the anesthesia, nor in the comfort 
of the patient, but there was a little more bronchial irritation 
following operation when nitrous-oxide-oxygen gas had been used.” 
He found the method cumbersome and permanently abandoned it. 

One sees frequently in reviewing the literature on nitrous-oxide- 
oxygen anesthesia the statement, especially by those who favor 

1 Johnson’s Oper. Ther. 

2 Med. Rec., July 29, 1916. 

3 Manual of Surgery, 1915. 


THE DANGERS OF GENERAL ANESTHESIA 


29 


its usage, that it causes death only by asphyxia and if the mixture 
contains sufficient oxygen, or if oxygen is pushed on the appearance 
of cyanosis, asphyxia does not occur. This can hardly account 
for the many sudden deaths which have occurred during apparently 
tranquil administrations without any of the recognizable danger 
signals of asphyxia appearing. Some of these deaths have occurred 
as quickly as six minutes after the patient entered the operating 
room and some while the gas was being given as a preliminary to 
ether. They took place without any warning and were apparently 
due to heart failure. It is definitely established that nitrous 
oxide is an extremely dangerous drug in the hands of the untrained, 
and to be considered comparatively safe it must be administered 
by an expert. 

THE DANGERS OF GENERAL ANESTHESIA. 

The dangers of general anesthesia are many when one pauses 
to consider them. The causation or augmentation of an acidosis, 
the pulmonary irritation contributing to a postoperative pneumonia 
among the other toxic effects of the drugs enumerated in the pre¬ 
vious pages, are all dangers which must be ascribed to the direct 
action of the anesthetics. 

The direct danger, usually the only one considered by the laity, 
and by some operators, is death during administration. Many 
series of statistics have been compiled as to the death rate of each 
anesthetic but they differ greatly and are perhaps of very little 
practical value. The part played by faulty surgical technic, 
surgical accidents, unskilled operating and the previous serious 
condition of the patient with lowered resistance is difficult to 
ascertain in many cases, and frequently the death on the operating 
table was assumed to be due to the anesthetic. However, death 
from the anesthetic during the operation is a possible danger and 
must be remembered. In this connection one should not except 
nitrous-oxide-oxygen anesthesia, which even Crile states is the 
most dangerous in unskilled hands. And everyone knows how 
often it is given by a nurse or intern who is unskilled in its adminis¬ 
tration. The death rate of this anesthesia from 1905 to 1911 
according to one report was 1 in every 657. 1 

Most important among what may be termed the indirect dangers 
is perhaps tissue trauma. Unnecessary traumatization of the 
tissues occurs in two ways. To shorten the duration of the anes¬ 
thetic, the surgeon hastens through the operation and in so doing 
tears and bruises the tissues instead of carefully dissecting them. 


1 Sajous’ Cyclopedia, vol. 9 , p. 149. 


30 


THE GENERAL ANESTHETICS 


The unconsciousness of the patient allows the operator not only 
to do this but to handle, sometimes roughly and needlessly, such 
organs as the intestine, stomach and gall-bladder. Many times 
has the author seen in the best and largest clinics in the country, 
the surgeon actually fighting the loops of bowel as they insisted 
on protruding from the abdominal wound during general anes¬ 
thesia, until the gut became congested and even bled. This pro¬ 
trusion of the bowels is due to the positive intra-abdominal pres¬ 
sure which often exists. This needless trauma is undoubtedly 
a great factor in the production of shock, as has been brought 
out by F. C. Mann 1 and many others. 

Fatal accidents have occurred on the operating table from 
objects such as false teeth or tobacco plugs falling into the air 
passages and causing asphyxia. Vomited material has also been 
drawn into the larynx in many cases. A less serious danger and 
cause of labored and stertorous breathing or even asphyxia is the 
falling back of the tongue into the throat due to the relaxation of 
the muscles. This, of course, may be relieved at once by drawing 
the tongue forward but it is a cause for anxiety when not recog¬ 
nized by the anesthetist. Similar symptoms may be caused also 
by an accumulation of saliva, mucus or blood in the throat. 

After leaving the operating room and returning to the bed, the 
indirect dangers from the anesthetic may continue to occur. Dur¬ 
ing the awakening, vomiting occurs very frequently and this together 
with struggling which is sometimes seen, causes a strain on an 
abdominal or herniotomy wound which may attain dangerous 
proportions. It is difficult to say just what proportion of incisional 
hernias are due directly to postoperative strain but this is no 
doubt an important factor. 

Head and neck wounds may be soiled by material vomited both 
during the operation and also during the awakening of the patient. 

The helplessness of the patient before he has fully regained 
consciousness is accountable for another accident which is not 
uncommon. That is burning with hot water bottles which have 
been placed about him. 

The spread of infectious material and other accidents are referred 
to in Chapter III, under a consideration of the anesthesia problem. 

All these dangers may appear superfluous to the reader, but 
they are realities and occur not infrequently. 

Thompson 2 of the school of general anesthetists, in a review 
of the postoperative morbidity in its relation to general anes¬ 
thetics appreciates the dangers and attempts to ward off the unde- 

1 Jour. Am. Med. Assn., 1917, 69 , 371-374. 

2 Postoperative Morbidity in its Relation to General Anesthesia, Edinburgh Med. 
Jour., June, 1921, 26 , 356. 


MORTALITY OF THE GENERAL ANESTHETICS 


31 


sirable features by means of a prophylactic regime which is highly 
laudable and with few exceptions is not only applicable when 
local anesthesia is substituted but should be demanded. He 
would ward off nausea and vomiting and a tendency to lowered 
alkali reserve by avoiding fasting and purgation, and by preliminary 
administration of sodium bicarbonate until the urine is no longer 
acid. He emphasizes the importance of gentleness in operative 
manipulations and the avoidance of unnecessary movements as well 
as chilling during the transfer of patients to and from the operat¬ 
ing room. He advocates the use of atropine and morphine to 
reduce the amount of general anesthetic to the minimum, prefers 
nitrous oxide and oxygen to ether and refrains entirely from giving 
ether to one who has recently had bronchitis. 

Other authorities on general anesthesia realize its dangers and 
Guedel 1 suggests a remedy in a recent report on the “Present 
Status of General Anesthesia” by restricting its administration 
to physicians and dentists who have taken graduate study in this 
specialty. Baily 2 in a review of 1000 cases of general anesthesia 
likewise believes that except in emergencies general anesthetics 
should be given only by expert anesthetists, and these should 
possess a medical degree and license to practice medicine and 
surgery. 


MORTALITY OF THE GENERAL ANESTHETICS. 


The statistics which have been compiled on deaths occurring 
during and from general anesthesia are abundant and extremely 
variable. The more one studies the literature on this subject, 
the more he is impressed with the fact that such statistics are 
practically worthless. As one writer, W. Hamilton Long 3 has 
said, “One is reminded at times of the axiom, ‘Figures don’t 
lie, but liars will figure,’ ” or as Sir Berkeley Moynihan has said, 
“One can prove almost anything by statistics, even the truth.” 

There are logical reasons why our statistics do not represent 
the actual truth. When death occurs during an operation, it is 
not an easy matter satisfactorily to prove that the anesthetic is 


the cause. A thorough postmortem examination is necessary 
to decide this and this procedure is perhaps not undertaken in the 
majority of cases. Doubt as to the real cause of death in these 
uninvestigated cases simply tends to prompt the surgeon not to 
report the case. 

Thus many deaths are never reported, especially those occur- 


1 Present Status of General Anesthesia. Some Observations and Conclusions, 
Boston Med. and Surg. Jour., August 4, 1921, 185 , 147. 

2 One Thousand Cases of General Anesthesia. Some Observations and Conclu¬ 
sions, Boston Med. and Surg. Jour., August 4, 1921, 185 , 147. 

3 Kentucky Med. Jour., May, 1919, p. 200. 


32 


THE GENERAL ANESTHETICS 


ring in doctors’ offices and in residences where operations are 
performed, or in hospitals which keep no careful systematic records. 
Those occurring in the hands of the inexperienced, as interns and 
nurses, are very apt not to be reported. 

Possibly the fact that death due to the anesthetic does not 
help the reputation of either the surgeon or anesthetist, results 
in a tendency to suppress the truth. 

However, some of the most reliable statistics will give us an 
idea of the comparative or relative safety of the substances used. 
The figures given by Gwathmey 1 in his great work on anesthesia 
are perhaps the most reliable today: Nitrous-oxide-oxygen, no 
deaths in 8585 cases. Ether alone, 28 deaths in 157,453 cases, 
giving a death ratio of 1 in 5623 cases. Nitrous-oxide-ether, 6 
deaths in 41,435 cases with a ratio of 1 in 6905 cases. Chloroform, 
8 deaths in 16,390 cases—ratio 1 in 2048. 

These statistics were gathered, however, before nitrous-oxide- 
oxygen came into such general use as it is today. Not infrequently 
in more recent literature do we find deaths reported from this 
anesthetic. It is difficult to say, therefore, what even an approxi¬ 
mate ratio would be in this case. Crile states that in unskilled 
hands it is the most dangerous of all anesthetics. Inasmuch 
as it has its definite limitations and is undoubtedly given by many 
who are incompetent the author feels that it is not much safer, 
if as safe, than ether. However, the rapid improvement in the 
method of its administration should make its use more trust¬ 
worthy as time goes on. It has its most successful application 
when given with local anesthesia as Crile has shown. 

Hewitt’s English statistics are approximately the same as those 
of Gwathmey. 


A. S. McCormick 2 gives the following statistics: 

Chloroform: Death rate, 1 in 2000 cases. In warm climates it 
is safer, the ratio being 1 in 8000 cases. 

Nitrous Oxide: Nitrous oxide is a dangerous anesthetic. It is 

safer when combined with oxygen, but is losing 
ground. The death rate was 1 in 657 cases 
from 1905 to 1911. 


Ether: Ether is the safest and best of all the general anesthetics. 
As to the death rate the figures vary: 

Wharton’s ratio—1 in 16,000 cases. 

Baldwin’s ratio—1 in 50,000 cases. 

Boosing’s ratio (Denmark) —1 in 56,000 cases. 

Mayo Clinic—Ether was given 49,037 times in thir¬ 
teen years (1900 to 1912) without causing death. 
Ethyl Chloride: Death rate, 1 in 2500 cases. 


1 Anesthesia Text-book. 

? Summit County Medical Sqciety, Akron, Ohio, November 1, 1916, 


CHAPTER II. 


THE LOCAL ANESTHETICS. 

It is unnecessary to write at length concerning the history of 
local anesthesia. Many excellent accounts of the innumerable 
attempts made to produce local anesthesia since ancient and 
medieval times may be found in the literature, especially in some of 
the text-books on this subject. Suffice it to say that the important 
discoveries which have done most toward developing our modern 
successful methods of inducing anesthesia locally are the following: 

In 1853, Alexander Wood of Edinburgh discovered that hypo¬ 
dermic injections could be given by means of a hypodermic needle. 
This led to the introduction of drugs beneath the skin where they 
could come in direct contact with the many branching sensory 
nerve fibers and their endings and also the larger nerve trunks. 
This discovery was without much value, however, until a suitable 
drug could be found which when injected into the tissues would 
exert a quick local anesthetic action. The second most important 
step therefore came in 1884 with the introduction of cocain by 
Carl Koller, although the alkaloid had been first isolated by Gardeka 
in 1855. Shortly after the introduction of this drug, operations 
such as amputations, tracheotomies and herniotomies were suc¬ 
cessfully performed without pain to the patient. The toxicity 
of cocain was nevertheless a drawback and accounted for many 
unhappy results. It may be said, therefore, that in the history of 
local anesthesia there is a third milestone representing the intro¬ 
duction of novocain by Einhorn in 1905. This drug, which is 
used most extensively today, is much less toxic than cocain and 
besides possesses other qualities which make it almost ideal in this 
work. 


METHODS OF PRODUCING LOCAL ANESTHESIA. 

Cold.—Besides the above method of producing local anesthesia, 
which is by far the most extensively used, there is another which 
may be said to have its place in minor surgery, namely, cold. 
This was first applied as far back as the sixteenth century but 
possessed little if any practical value until Richardson in 1806 
devised the ether spray or atomizer in which drugs such as ether, 
ethyl bromide, ethyl chloride and others, which have low boiling 
3 


34 


THE LOCAL ANESTHETICS 


points, could be used. More recently the ether spray of Richardson 
has been replaced by sprays of more rapid action. Ethyl chloride, 
methyl chloride and liquid carbonic acid gas are the drugs which 
are most used today since they have a much lower boiling point 
than ether, produce intense cold on evaporation, and freeze the 
tissues very quickly. As these substances change to gas at room 
temperature and under normal atmospheric pressure they must 
be kept in containers under pressure. 

Although this method of producing local anesthesia has been 
used in a few instances in quite extensive major surgical procedures, 
its real value lies in the performance of such superficial minor 
operations as the opening of furuncles or subcutaneous abscesses, 
or in the removal of splinters from beneath the skin. It is a time- 
saver in these simple procedures. 

Pressure.—Prolonged pressure when exerted upon any part of 
the body causes a numbness and if continued long enough an 
anesthesia of that part. This fact was observed centuries ago 
and this procedure was resorted to for many years in order to 
obtain decreased nerve sensibility in surgical procedures. The 
method fell into disrepute eventually both because the pressure 
exerted caused much pain and not infrequently atrophic changes 
and even necrosis peripherally, and also because more efficient 
methods were discovered. Constriction or pressure is practically 
never used today to produce local anesthesia, unless perhaps by 
some of the uncivilized races. 

Phenol.—The escharotic action of carbolic acid when applied 
to the skin limits its employment to but a few areas and here anes¬ 
thesia may be produced more quickly by a cold spray or the injection 
of cocain or one of its substitutes. The injection of a weak car¬ 
bolic solution into the tissues is accompanied by pain and is likely 
to be followed by tissue necrosis. 

Sorisi 1 and others have recommended the use of pure carbolic 
acid as an anesthetic for making incisions in infected cases where 
drainage is to be employed and where primary healing is not to 
be expected. He describes the technic thus: A dry scalpel is dipped 
into phenol and the back of the scalpel and the point of the blade 
is passed over the skin to be incised. After waiting a few minutes 
the scalpel is again dipped into the phenol and the incision begun. 
Repeated carbolizations of the scalpel are required as the incision 
progresses. He has used it successfully in over 3000 cases. 

Other agents which have been claimed in past years by some 
workers to be useful in the field of local anesthesia, but which 
have been discarded after the introduction of better and more 


1 Jour. Am. Med. Assn., May 3, 1919, 72, 1288. 


METHODS OF PRODUCING LOCAL ANESTHESIA 


35 


active drugs are chloroform, alcohol, morphin, sodium and potassium 
bromide, chloral, brucin and antipyrin. 

Cocain.—Cocain is methyl benzoylecgonin, the formula being 
C 5 H 7 (CH 3 )NCH(OCOCH 5 ) — (CH 2 COOCH 3 ). The two official 
preparations of the drug are the alkaloid and the hydrochloride. 
Death has been recorded following very small doses, for example 
as 16 and 40 mgm. On the other hand, patients have been given 
over 1 gm. subcutaneously and survived. Walter Wildenrath 1 
gives a good bibliography of cocain poisoning. A non-fatal intoxi¬ 
cation is characterized at first by nervousness, rapid pulse, increased 
reflexes, deepened respirations and vertigo. Later nausea and 
vomiting follow and there may be clonic spasms of the muscles 
of the limbs. The pupils become markedly dilated. 

It was not until twenty-five years after the discovery of cocain 
in 1857 that the attention of the medical profession was directed 
to its remarkable anesthetic properties. It was first used in surgery 
of the nose, throat, rectum and urethra, by direct application of 
5 to 20 per cent solutions to the mucous membranes of these parts. 
It became very popular in a short time as its use was extended to 
the performance of many different operations in general surgery 
and also in dentistry, by injecting its solutions into the tissues. 
But cases of acute poisoning and death began to occur with increas¬ 
ing frequency. The danger of the formation of the drug habit 
was also observed. It was not long before the profession realized 
that cocain was not the ideal drug in this field. Not only its 
dangerous qualities but its irritating effect upon the tissues and 
the impossibility of sterilizing it in solution without deterioration 
were factors which led to its abandonment as a local anesthetic 
except in eye and nasal surgery, and perhaps occasionally in throat 
and urethral operations. 

It was the necessity for the elimination of these undesirable 
qualities that gave rise to the long research in synthetic chemistry 
by which a series of substitutes were discovered. These com- 
pounds, which belong to several general chemical groups, possess 
the common property of producing local anesthesia, and, as has 
been brought out by Eggleston and Hatcher of Cornell University, 
resemble one another very closely in their important pharmaco¬ 
logical actions, such differences as are shown being chiefly 
quantitative. In testing out the value of these substitutes, isotonic 
solutions of cocain have been used as a standard of comparison. 
Only the more important of these substitutes will be considered. 

Beta-eucain.—Beta-eucain is one of the first compounds dis¬ 
covered by the synthetic chemist (Vinci, 1897) to be less toxic 


1 Friedreich’s Blatt. f. gericht. Med., 1911, 62, 215, 


3G 


THE LOCAL ANESTHETICS 


than cocam. It is a benzoyl derivative and chemically closely re¬ 
lated to tropacocain. The hydrochloride and lactate are employed, 
the latter being used when strong solutions are desired as it is more 
soluble (to 22 per cent) than the former. Its solutions are stable 
and may be sterilized by boiling after which adrenalin is added. 

It has been used quite extensively in nasal operations and found 
to be safer than cocain and yet as efficient in producing anesthesia, 
although a stronger solution must be used. Various authors have 
reported its successful usage in the performance of major operations 
such as herniotomies, thyroidectomies, appendectomies, breast 
amputations and gastrostomies. 1 

We have tested this drug and find that though an excellent 
anesthetic, it must be used with caution on account of its high 
toxicity. 

As to its toxicity, the opinions of investigators vary. All are 
agreed, however, that it is less toxic than cocain. Only a few cases 
of acute poisoning have been reported in the literature. Kraus 2 
reports a severe reaction following the injection of 10 cc of a 2 
per cent solution into the urethra. Way 3 also records a serious 
intoxication with convulsions following infiltration for circumcision 
of 0.12 gm. in solution. Marcinowski has reported 2 cases of 
intoxication. 

Beta-eucain was for some time the most satisfactory substitute 
for cocain in general surgery and hence served as a stepping stone 
in the progress of local anesthesia. Its solutions cannot be rapidly 
injected in infiltration work without discomfort and they are quite 
slowly diffusible, a ten to thirty minute delay being necessary 
before the operation can be begun with complete anesthesia. Its 
use today is confined largely to dentistry and to work in the nose. 

Tropacocain.—T 'ropacocain was first isolated from the coca 
plant by Giesel, 1891. It is made synthetically and is a white 
crystalline powder readily soluble in water. The hydrochloride 
is used and its solutions may be sterilized by boiling without des¬ 
troying its properties. 

It has been found that it is much less toxic than cocain but 
must be used in much more concentrated solutions to obtain the 
same degree of anesthesia. In infiltration work, it produces a 
greater irritation than does cocain solutions and its effects are of 
shorter duration. 

By some who are experienced in spinal anesthesia, first suggested 
by J. L. Corning 4 in 1885, who, however, used 2 per cent cocain in 

1 Witherspoon: St. Louis Med. Review, March 24, 1906. 

2 Deutsch. med. Wchnschr., 1906, 32, 67. 

3 Jour. Roy. Army Med. Corps, London, 1914, 23, 209, 

4 New York Med. Jour., October 31, 1885, 


METHODS OF PRODUCING LOCAL ANESTHESIA 


37 


his experiments on dogs, it is said that tropacocain is the ideal 
agent for this procedure. The author has had no experience with 
it. G. MacGowan 1 of Los Angeles has used it for more than 
fifteen years intraspinally, giving 6 to 12 eg. of the dry powder, 
dissolved in the spinal fluid, and reports but 1 case in which the 
patient manifested alarming toxic symptoms. G. F. Thompson 2 
has used it in 1000 cases. 

Stovain. — Stovain is a white powder easily soluble in water. 
It was first introduced by Tourneau 3 as a substitute for coeain. 
There are many disadvantages connected with its use. Its solutions 
are decomposed when heated to 120° C., and it is said that adrenalin 
cannot be used with it. 

Many who have used it for infiltration anesthesia have found it 
to be irritating and painful, even in weak solutions. French 
surgeons have recommended it highly for spinal anesthesia but 
there have been many unfavorable reports of it in this field, espe¬ 
cially in some foreign journals. Some workers recommend it for 
instrumental examination of the urethra and bladder, instilling 
about 15 cc of a 1 per cent solution. 

The technic for spinal anesthesia as used by Dr. Morrison 4 
who has done 11,000 cases requires the use of a platinum needle 
6 cm. (2 inches) long. The patient is seated with the back arched 
when possible. The space indicated is chosen and as much fluid 
is withdrawn as is wished to be injected. He uses a stovain solution 
made up in 0.7 \ cc ampoules and adds J to 1 mm. strychnin, 
and after the injection he is able to do bilateral herniotomies, 
hydroceles, ventral herniotomies, thoracostomy, hysterectomies, 
nephrectomies, splenectomy, etc., and he uses this form of anesthesia 
in 97 per cent of his surgical operations. In operations about 
the head and neck, he uses local anesthesia. Headache has been 
the principal and most persistent objection to his technic, and he 
has been unable to eliminate this drawback. This he attributes 
to over-activity of the patient after the injection, as it is usually 
more pronounced in the minor cases. 

In cases of overdose manifested by anxiety, pallor, and nausea, 
he gives 2 tablespoons of brandy by the mouth and 20 minims of 
camphor in oil by hypodermic, and employs artificial respiration. 
Flertz 5 injects 0.25 gm. caffein subcutaneously as a prophylaxis; and, 
at the slightest sign of mydriasis, pallor or relaxation of the sphincter, 


1 California State Jour. Med., January, 1916, p. 6. 

2 Journal-Lancet, June 1, 1921, 41, 318. 

3 Allen, Local Anesthesia, p. 83. 

4 British Med. Jour., November 5, 1921, p. 745. 

6 Paris Medical, March 11, 1922. Abstract, Jour. Am. Med. Assn., April 29, 1922, 

78, 1348. 


38 


THE LOCAL ANESTHETICS 


he repeats the injection of caffein and in grave cases, he injects 
the caffein directly into the spinal canal, lowering the head. 

Recently Gosset and Monod 1 have reported a series of cases 
in which stovain was used and they believe spinal anesthesia is 
reliable for operations below the thorax and have never had a 
fatality in their more than 2000 applications of it. They refrain 
from its use, however, in cases of hypotension, subnormal tempera¬ 
ture, tuberculosis and acute peritonitis. They attribute 2 fatalities 
to the ether which superimposed defective spinal stovain anesthesia 
in these 2 cases of acute peritonitis, and advise against this 
form of anesthesia in such condition. At Salpetriere during 
1921, 442 surgical operations were done with spinal anesthesia, 
300 with ether, 71 by nerve blocking and 3 with chloroform. 

Alypin.—Like stovain, this is a derivative of the benzoyl group 
and was introduced in 1905 by Impens and Hofman. 2 It is a 
white crystalline neutral powder, very soluble in water and is not 
precipitated by alkaline fluids. Its solutions may be boiled for 
ten minutes without impairing its properties and it is compatible 
with adrenalin. 

A review of the literature on this drug shows a great difference 
of opinion regarding its action and toxicity. Some observers have 
lauded it while others assert that the anesthesia produced is very 
weak. 3 It has been found that its lethal dose in dogs and cats 
is about double that of eocain. A. H. Miller 4 has reported a 
series of 103 cases in which alypin was used. 35 of these were 
minor surgical operations and 68 genito-urinary. In 100 cases, 
the analgesia was perfectly satisfactory, in 2 it caused serious 
difficulty, and in 1, instant death. In this case 8 cc of a 10 per 
cent solution were introduced into the urethra and bladder. Death 
followed in about twelve minutes, being preceded by convulsions. 

Alypin only partially meets some of the shortcomings of cocain. 
Injection of its solutions into tissues as ordinarily used often causes 
a slight burning, and usually is followed by some hyperemia. In 
some cases a slight inflammation has resulted. Its use is recom¬ 
mended by many for eye, nose and throat operations, and by a 
few for the genito-urinary tract. 

Apothesin.—Apothesin, a synthetic drug, is the hydrochloride 
of diethylamino-propylcinnamate. It is easily soluble in water, 
making a stable solution and hence may be sterilized by boiling. 

This drug is listed in the “Described but Not Accepted” depart- 

1 Paris Medical, March 11, 1922. Abstract Jour. Am. Med. Assn., April 29, 1922, 
78, 1348. 

2 Arch. f. d. Ges. Physiol., 1905, 110, 21. 

3 Wolff Freudenthal: Med. Rec., July 20, 1912. 

4 Jour. Am. Med. Assn., July 17, 1914. 


METHODS OF PRODUCING LOCAL ANESTHESIA 


39 


ment of New and Non-official Remedies, but is ineligible to inclusion 
in New and Non-official Remedies, as its makers claim for it an 
efficiency 1 and low toxicity which are not justified by acceptable 
scientific evidence. 

The Council on Pharmacy and Chemistry of the American 
Medical Association states in its recent report that the toxicity 
of apothesin is to the toxicity of cocain as 20 is to 15 and that it 
has about twice the toxicity of procain. 

It is used quite extensively by some surgeons for infiltration 
anesthesia and would be a most valuable drug if there were not 
others which are more efficient and less toxic. 

Allocain-S.—A comparatively new local anesthetic known as 
allocain has been discovered by Seiko Kubota, in the pharmaco¬ 
logical laboratory of the Japanese Medical School at Mukden. 
It is a white odorless powder consisting of fine needle-like crystals 
with a bitter taste. It dissolves easily in water with a neutral 
or slightly acid reaction. Its chemical reactions resemble very 
much those of cocain. It is a weak base and is easily precipitated 
from solution of its salts in the presence of alkalies. 

After experimenting on frogs and rabbits, Kubota concludes as 
follows: 2 

1. Allocain-S. possesses a stronger anesthetic power than pro¬ 
cain and a weaker one than cocain. 

2. It is less toxic than either cocain or procai,n. 

3. Subcutaneous injections cause a slight local irritation. 

4. It inhibits the growth of both streptococci and staphylococci. 

5. It possesses a good character as a local anesthetic in many 
respects, but on the other hand, it has also some unfavorable quali¬ 
ties. On account of the slight irritation by its acid solutions and 
of its precipitations by tissue fluids, its use is limited. 

In a later report the same author states that this substance has 
been tried in several hundred cases of operation with success. 
The results in these cases are in accord with the above conclusions. 
A slight irritation at the moment of injection was sometimes noted 
and in a few cases, a slight necrotic action was observed where 
it was applied several times in the same place. There is no record 
of the type of these operations nor how extensive they were. The 
reporter also fails to state how much of the drug was used in a 
single case. More recently a method of preparing this substance 
so that its solutions are less irritating to the tissues has been reported. 

Nirvanin.— Nirvanin represents the most valuable member for 
infiltration anesthesia, of what is called the orthoform group. 
It is a white crystalline powder, and unlike the other members of 

1 Council Report: Jour. Am. Med. Assn., January 24, 1920, p. 265. 

2 Jour. Pharmacol, and Exper. Therap., February, 1919, 12, 361. 


40 


THE LOCAL ANESTHETICS 


this group, is readily soluble in water. Its solutions may be 
sterilized by boiling and may be used with adrenalin. It is used in 
1 to 5 per cent solutions. 

This drug has not been used very extensively to produce local 
anesthesia, especially in major operations. Those who have 
employed it, report satisfactory results when it is used for the 
production of limited infiltration anesthesia. It has a use in 
dentistry. 

The other members of the group are orthoform, subcutin, anes- 
thesin, zvkloform and propsesin and are only slightly soluble in 
water. They have been used in dusting powders and ointments 
upon the skin; in suppositories and ointments in the rectum or 
vagina; and also in the nose, throat and intestinal tract. Anes- 
thesin is said to be the most efficient. 

Quinin and Urea Hydrochloride.—Practically the only quinin 
salt of value in local anesthesia is the double hydrochloride of quinin 
and urea. This salt, used in water solutions of from 0.25 to 1 
per cent, was introduced into practice by Thibault 1 in 1904. 

The quinin and urea compound is made by dissolving quinin 
hydrochloride in hydrochloric acid, adding pure urea, filtering 
the mixture through glass wool, and allowing it to crystallize. 
The crystals are white and soluble in an equal part of water. Its 
anesthetic action is thought by some to be due to coagulation of 
the protoplasm of the peripheral nerves. 

The fact that quinin and urea hydrochloride has not become 
popular as a local anesthetic is in part due to the formation of a 
fibrous exudate in the tissues after they are infiltrated with it. 
It is claimed this seriously delays the healing of the wounds. Hertz- 
ler, Brewster and Rogers 2 state that this induration and thicken¬ 
ing, instead of being cellular, is due to a purely fibrinous exudate 
which is nearly all absorbed in the course of a few weeks or months, 
and when a 0.25 per cent solution is used, this induration does 
not occur to any notable degree. 

The drug has two great advantages. It is perhaps the least 
toxic of all the local anesthetics. The difference in toxic power 
between cocain and the quinin salt may be expressed by a ratio 
of at least 40 to 1. No constitutional effects may be feared from 
its free use, except in individuals with a marked idiosyncrasy. 
The second advantage is the long duration of its anesthesia. This 
varies greatly according to different observers, but frequently 
decreased sensation exists for several days. In such operations 
as the removal of hemorrhoids, when pain is likely to persist for 
some time, infiltration of the tissues with a 0.25 per cent solution 

1 Jour. Arkansas Med. Soc., September 15, 1907. 

2 Jour. Am. Med. Assn., October 23, 1909. 


METHODS OF PRODUCING LOCAL ANESTHESIA 


41 


of quinin and urea lias a distinct advantage. It lias been observed 
also by many workers that the drug possesses a decided hemostatic 
effect, especially when 1 to 4 per cent solutions are used. 

The author uses a 1 to 600 solution routinely in all operations 
about the anus and in tonsillectomies, but only after completing 
the operations under novocain anesthesia. This procedure results 
in prolonged anesthesia with much comfort to the patient and it 
profitably utilizes the hemostatic effect of the drug, thereby pre¬ 
venting secondary oozing. The fibrinous reaction does not inter¬ 
fere with the normal healing by granulation of these wounds. 
We have found that the introduction of quinin solutions into the 
skin causes a momentary burning or painful sensation. 

Benzyl Alcohol.—In testing the taste of this drug, D. I. Macht 1 
found that it produced a numbness of the tongue. Following this 
discovery, experiments proved that this drug produced anesthesia 
of the sensory nerve endings. 

Benzyl alcohol is a simple organic compound, its formula being 
CeHsCFFOH. It is a clear liquid with a faint aromatic odor. 
Its boiling point is high, 204.7° at 760 mm. pressure. Hence its 
solutions may be sterilized by boiling without destruction of the 
active principle. It is soluble up to 4 per cent in water and is 
used in from 0.5 to 4 per cent solutions. It is compatible with 
adrenalin. 

Macht after a careful series of experiments reports the following 
regarding its efficiency and toxicity: 

A 1 per cent solution applied to the tongue produces anesthesia 
which may last one-half hour. A 1 per cent solution in the con¬ 
junctival sac produces anesthesia of the cornea as early as one to 
two minutes. Very slight irritation of the conjunctiva was noticed. 
A pledget of gauze soaked in a 1 per cent solution of benzyl alcohol 
in normal saline placed about the dissected sciatic nerve of a dog, 
paralyzed sensory conduction in about five minutes. Experi¬ 
ments on dogs and rabbits indicate that its toxicity is very low. 
A dog weighing 8.7 kilos was given intravenously 44 cc of a 4 per 
cent solution in saline with only mild toxic symptoms and a partial 
general anesthesia. Recovery was complete in one-half hour. 
Another dog weighing 7.3 kilos was given the same dose without 
any toxic symptoms. 

Macht also found that injection of 1 to 4 per cent solutions 
produced no marked irritation or destruction of the tissues, at 
least no more than that produced by an equivalent amount of 
quinin-urea hydrochloride. He reports its successful use in about 
fifty minor operations in which the anesthesia was efficient and 
very satisfactory. 


1 Jour. Pharmacol, and Exper. Therap., April, 1918. 


42 


THE LOCAL ANESTHETICS 


Sollmann 1 after a series of experiments lias concluded that 
benzyl alcohol is a fairly efficient anesthetic for intact mucous 
membranes, greatly surpassing procain; ranking about with alypin 
and beta-eucain; and somewhat weaker than holocain or cocain. 
Its action is not as lasting as that of cocain and even 1 per cent 
solutions produce considerable smarting. He states that com¬ 
mercial solutions in ampoules appear to deteriorate somewhat, 
so that it is preferable to use freshly made solutions when possible. 

As far as one can learn from the literature, benzyl alcohol has 
not been used very extensively in major operations. The author 
has had no experience with the drug in local anesthesia. 

Benzylcarbinol. — II jort and Eagan 2 claim that benzylcarbinol, 
or rose oil, an aromatic side-chain alcohol, possesses local anes¬ 
thetic properties which from laboratory studies seem to be superior 
to those of benzyl alcohol. The toxicity of rose oil, as determined 
on white mice and dogs, is about the same as that reported by 
Macht for benzyl alcohol. See page 41. Its solubility is sufficient 
for its therapeutic use. 

Saligenin (Salicain).— Saligenin or salicyl alcohol (CTTOH- 
CH 2 OH), allied chemically to benzyl alcohol, has been shown to 
possess greater local anesthetic properties than the above mentioned 
drugs by Hirschfelder 3 and others. 

From experiments on the exposed sciatic nerve of the frog, 
injections into frog lymph sacs and subcutaneous injections in 
man, they show that the presence of the hydroxyl group in the 
ring increases the anesthetic power of saligenin and homosaligenin 
whereas the prolongation of the side chain, or when the hydroxyl 
group is covered with a methyl or an ethyl group, the anesthetic 
power is diminished. 

The toxicity of saligenin is quite low. 1 gm. per kilo given 
subcutaneously causes depression and transient paralysis of the 
hind legs in rabbits, but 0.125 to 0.5 gm. per kilo does not produce 
albumin or casts in the urine of rabbits or dogs. The lethal intra¬ 
venous dose was found to be 0.4 to 1 gm. per kilo for dogs so that 
rapid intravenous injection of more than necessary to perform an 
ordinary minor surgical operation in man produced little effect 
on the respiratory center and only a slight fall of blood-pressure 
in dogs. 

Of all the phenolic alcohols, it was concluded that saligenin was 
the least toxic, had the least tendency to wheal formation, stood 
highest in selective action of sensory nerve blocking and that it 
induced anesthesia longer than procain or benzyl alcohol. 

1 Jour. Pharmacol, and Exper. Tlierap., July, 1919, p. 355. 

2 Ibid., November, 1919, p. 28. 

3 Ibid., June, 1920, 15 , 4. 


METHODS OF PRODUCING LOCAL ANESTHESIA 43 

Nine tonsillectomies, 2 sebaceous cyst removals, 2 great-toe 
matrix removals, an inguinal hernia, a mandibular block and 
16 cystoscopies are reported in which saligenin (2 to 4 per cent) 
was used successfully by various surgeons. 

The author has used saligenin in 25 instances of major surgery, 
over one-half of the operations being very extensive in character, 
notably perforating gastric ulcer, intrathoracic goiter of the toxic 
type and abdominal hysterectomy. There was not the slightest 
sign of toxicity although comparatively large amounts of the 
solution were used. However, it was found that the action of 
the drug was somewhat slow as compared with novocain and that 
in solution weaker than 2 per cent anesthesia was unsatisfactory. 
On account of its low toxicity this drug bids fair to become exceed¬ 
ingly useful. 

The more recent use of this drug by the author gives the 
impression that at least 4 per cent solution must be used in order 
to obtain satisfaction. 

Butyn.—Butyn is a normal sulphate of a base resembling the 
base of procain but differing in that it possesses a butyl group in 
place of the ethyl group and a propanol group in place of the ethanol 
group in the procain base. Its formula is as follows: (NI4 2 C 6 H 4 - 

COO(CH 2 ) 3 N(C 4 H9) 2 )2 h 2 so 4 . 

As a local surface anesthetic it is proposed as a substitute for 
cocain in eye and throat work. A 0.5 per cent solution on the 
normal human conjunctiva is more efficient than a 1 per cent 
solution of either cocain or eucain and it is non-irritant. When 
given hypodermically in rats it is two and a half times as toxic as 
cocain but intravenously in cats the lethal dose equals that of 
cocain. Thus it does not appear promising for injections or spinal 
anesthesia since it is more toxic than procain. 

A committee of the Section on Ophthalmology of the American 
Medical Association 1 reports the successful use of butyn in practi¬ 
cally all operations on the eye and in some of the nose and throat. 
It also concludes that butyn is more powerful than cocain, a smaller 
quantity being required; it acts more rapidly than cocain and the 
action is more prolonged; it is less toxic than cocain; it does not 
dry the tissues as does cocain; it does not change the size of the 
pupils, and it has not the ischemic effect of cocain. 

For ophthalmic work a 2 per cent solution is used and four 
instillations, three minutes apart produce the anesthesia desired for 
all of the commoner operations of the eye. In nose and throat 
work 2 to 5 per cent solutions are used. It may be boiled to 
sterilize and epinephrin may be added as with other solutions. 


1 Jour. Am. Med. Assn., February 4, 1922, 78 , 343. 


44 


THE LOCAL ANESTHETICS 


Epinephrin.—This drug has had a marked effect upon the prog¬ 
ress of local anesthesia. 

In this connection it may be well to briefly review epinephrin, 
as described by Sollmann. 1 

It is the active principle of the medulla of the suprarenal gland. 
Chemically it is an amin derivative of catechol and can be pre¬ 
pared synthetically. It behaves as a feeble base and might be 
classed as an alkaloid, and is represented by the following formula: 
C 6 H 3 (OH) 2 CHOHCH 2 MHCH 3 . 

Epinephrin is identical with the “chromaffin substance” of the 
suprarenal medulla discovered by A ulpian in 1856 and shown by 
Henle in 1865 to produce a green color with ferric chloride, pink to 
brown with alkalies, iodine or chlorin, or by oxidation, which may 
help to account for some of the various colored solutions noted 
after standing. The concentrated solutions deteriorate unless 
preserved with sulphite or chloroform. When dilute they deterior¬ 
ate within a few hours. 

V. Fuerth and Abel, in 1898, paved the way for the isolation of 
the active principle in crystalline form, and this was done by 
Takamine and Aldrich in 1901, and Abel in 1903. Abel and Macht 
also found considerable epinephrin in the parotid gland of the 
tropical toad (Bufa Agna). The structural constitution was 
determined by Jowett in 1904, although Aldrich established the 
empirical formula in 1902. The synthesis of the compound was 
accomplished by Stolz in 1904, Dakin in 1905 and Flacher in 1908. 
Since then various names, as adrenalin and suprarenin, have been 
used by the various manufacturers. 

'‘The typical action consists in a highly specific stimulation of 
the physiological endings of the entire sympathetic system, or 
when very dilute solutions are used the opposite effects may ensue. 
Thus the effect on any given organ depends upon whether such 
stimulation is augmentory, inhibitory or indifferent. The most 
important practical manifestation consists in a rise of blood- 
pressure from peripheral stimulation of the vasoconstrictor 
mechanism of the systemic vessels and of the accelerator mechanism 
of the heart.” 

The systemic action is very brief. Oral administration is entirely 
ineffective and intramuscularly it is moderately effective. Locally 
it arrests capillary hemorrhage and enhances the anesthetic effect 
of cocain (synergism; Esch, 1910) and its derivatives, and decreases 
their toxicity by delaying systemic absorption. 

Injection into the nasal submucosa has been shown by Pilcher 
(1914) to be almost equivalent to intravenous injection. None 


1 A Manual of Pharmacology, 1918. 


METHODS OF PRODUCING LOCAL ANESTHESIA 


45 


is absorbed through the nerves (Meltzer, 1909). Landau (1914) 
states that epinephrin does not produce glycosuria in man as it 
does in rabbits but that it increases the sensitiveness to an ali¬ 
mentary glycosuria. 

Meltzer and Auer 1 made an ocular study of the bloodvessels in 
the rabbit’s ear and showed conclusively that a subcutaneous 
injection of epinephrin causes a constriction of all the vessels of 
that ear. This is quite intense but the outstanding feature is 
its duration, three to eight hours. The period between the time 
of injection and the onset of constriction is longer the farther 
away the injection is from the principal artery. There is practi¬ 
cally an immediate paling of the entire ear and constriction of the 
central artery and vein with all the branches when an injection 
is made near the artery. The muscular sheath of the vessels is 
reached through the adventitia and not through the lumen and 
intima. After constriction there is a tendency to dilatation, and 
injection in one ear with constriction may result in dilatation of 
the other, which, however, is of short duration. 

Experimental work by Braun regarding the combined action of 
novocain-epinephrin, will be mentioned later and much credit must 
be given this worker for placing the use of the solution upon a 
stable, practicable basis following his application of it to numerous 
surgical operations. 

Novocain (Procain).— Novocain, a white crystalline powder, is 
chemically closely related to stovain and alypin. Its formula 
is as follows: CH 2 — (C 6 H 4 .NH 2 .COO).CH 2 [N(C 2 H 5 ) 2 ]—HC1. It is 
soluble in an equal part of cold water giving a neutral reaction. 
Its solutions possess slight antiseptic properties, may be repeatedly 
sterilized by boiling without marked effect upon the anesthetic 
properties, and may be kept for long periods of time (a quality 
not possessed by all other agents), without undergoing any change. 
Sodium bicarbonate may be added to the solutions without causing 
precipitation. 

When absorbed from the tissues, the general physiological action 
of novocain differs from that of cocain only in degree, as is the case 
with most of the other agents. As to its relative toxicity, the reader 
is referred to the latter part of this chapter. 

Locally, it exerts a prompt and pronounced anesthetic action 
which is greatly intensified by the addition of adrenalin, more so 
than with any of the other anesthetics. Although it is unnecessary 
to use stronger than a 2 or 4 per cent solution, a 10 per cent solution 
may be injected into the tissues without causing any irritation. 
There is no after-pain nor tendency toward the production of 
tissue necrosis, as with cocain. 


1 Jour. Pharmacol, and Exper. Therap., April, 1921, No. 3, 62, 177. 


THE LOCAL ANESTHETICS 


46 


Novocain is but mildly toxic. It is perhaps because of its low 
toxicity more than to its many other favorable qualities, that this 
drug has become the most widely used of all the local anesthetics. 
Allen 1 states: “After a rather extended experience, including a 
large number of cases embracing the entire field of surgery in which 
this agent has been almost exclusively used, we have failed to 
note a single case in which there has been any unpleasant local 
or constitutional action.” 

At the present time in the literature reports may be seen of the 
injection of comparatively large amounts of novocain solution 
without ill effect. The author has seen W. W. Babcock inject 
385 cc of a 1 per cent solution (3.85 gm.) the patient showing not 
the slightest toxic effect. While it is perhaps inadvisable to inject 
such large doses the fact that they can be injected without the 
patient showing any reaction proves that when properly safe¬ 
guarded novocain is an exceedingly safe drug. Novocain, like all 
other drugs, should be injected preferably in a weak solution and 
the dose should be measured in the strength of the solution rather 
than in its total amount by weight. 

In administering 5000 injections of the drug, Fischer failed to 
note a single case of serious intoxication. 

Granville MacGowan 2 of Los Angeles states: “In a very free 
use of it, ever since its introduction, I have never seen more dis¬ 
agreeable symptoms than a slight nausea, or a momentary faint¬ 
ness following its use.” The latter has used as high as 300 cc of 
a 1 per cent solution. 

The author has used the drug in thousands of cases and has 
never seen any serious toxic effects. 570 cc of a 0.5 per cent solution 
is the largest dose he has administered. 

According to Braun, 1.25 gm. (20 gr.) of novocain can be injected 
without fear of intoxication. That is 250 cc (8 oz.) of an 0.5 per 
cent solution or 125 cc of a 1 per cent solution. 

The toxicity of the drug is further reduced by the addition of 
from 2 to 5 drops of 1 to 1000 solution of adrenalin (epinephrin) 
to each 30 cc of novocain solution, which retards its absorption. 
In fact, the effects produced by the addition of this drug are nothing 
less than remarkable. Besides being prolonged, the anesthesia 
produced is intensified so that solutions of equal strength nearly 
equal in activity those of cocain. The experiments of Professor 
Braun 3 show clearly the remarkably favorable action obtained by 
the combination of adrenalin preparations with novocain besides 
its total absence of all irritation. It should be remembered, however, 

1 Local Anesthesia, 1914, p. 89. 

2 California State Jour. Med., January, 1915. 

3 Deutsch. meet Wchnschr., 1905, No. 42. 


METHODS OF PRODUCING LOCAL ANESTHESIA 


47 


that prolonged boiling decomposes the adrenalin; hence the latter 
should be introduced just before the operation. However, the 
adrenalin solution may be sterilized by initial boiling of the stock 
solution. 

For infiltration novocain solutions may be used in a strength 
of from 0.25 to 1 per cent. We prefer a solution between 0.7 and 
1 per cent. This, when combined with adrenalin, gives a most 
satisfactory anesthesia, especially in infiltration work. Braun, 1 
an eminent pioneer in local anesthesia in abdominal work, infil¬ 
trates the tissues with novocain and adrenalin dissolved in suit¬ 
able percentages in a solution consisting of potassium sulphate, 
4 parts, sodium chloride, 7 parts, and distilled water, enough to 
make 1000 parts. Sollmann states that potassium sulphate en¬ 
hances the anesthetic action of novocain so that by the addition 


of 2 per cent of the former the latter can be reduced 0.1 per cent. 
After a careful series of experiments 2 he concludes that mixtures 
of the anesthetic with potassium sulphate give only a simple sum¬ 
mation and that this would be of some advantage in reducing the 
required amount of the anesthetic, the conditions being more 
favorable than with mucous membranes which give not even 
summation; but too much should not be expected from the potas¬ 
sium mixtures. 

In contrast to the many general and local toxic manifestations 
of the general anesthetics, considered in the preceding chapter, 
is the almost total absence of perceptible changes in the body 
following the use of novocain. Like ether, chloroform or any 
other drug used in anesthesia, novocain is capable of producing 
severe, or even fatal, acute poisoning in man, but moderately large 
doses, when absorbed either intravenously or subcutaneously, 
show almost no noticeable change either upon the circulation or 
respiration. Also the blood-pressure remains practically unchanged. 

Gros asserts that upon the addition of 1 part of sodium bicar¬ 
bonate for every 4 parts of novocain employed, the anesthetic 
effect of the latter is at least doubled or trebled. Sollmann 3 con¬ 
cludes that anesthetic salts may be mixed with an equal volume 
of 0.5 per cent sodium bicarbonate solution without the loss of 
efficiency and with a saving of one-half of the anesthetic when 
mucous membranes are to be anesthetized. Alkalization does 
not increase the efficiency of novocain used in infiltration, however, 
and in this respect he also states that the anesthetic action of 
potassium sulphate or chloride is not great enough to be of real 
value, yet that it may be well to use a 1 per cent solution (isotonic) 


1 Zentralbl. f. Chir., 1913, 1513. 

2 Sollmann, Torald: Jour. Pharmacol, and Exper. Therap., No. 1, vol. 40 , p. 79. 

3 Therapeutic Research Reports, 1918, p. 20. 


48 


THE LOCAL ANESTHETICS 


which is equivalent to 0.125 per cent novocain, instead of sodium 
chloride. 

The author has tried the various combinations of drugs which 
it is claimed enhance the action of novocain and has been unable 
to satisfy himself that with the exception of adrenalin, any of the 
drugs recommended possess great advantage. 

ACIDOSIS RESEARCH UPON PATIENTS AFTER USING 

LOCAL ANESTHESIA. 

Recent experiments conducted in the author’s clinic by M. E. 
Rose 1 and lately reported, others by C. W. Brunkow at St. Mary’s 
Hospital, Minneapolis, and another series by S. R. Maxeiner and 
Frank Ilirschfeld at Minneapolis General Hospital, which have 
not been reported, tend to show that novocain produces a decrease 
in the alkali reserve of the blood, which is, however, less frequent 
and less marked than that following the use of general anesthetics. 
The alkali reserve of the blood of the surgical patients was deter¬ 
mined by Mrs. McGrath at St. Mary’s Hospital and Dr. Ikeda 
and staff of the Minneapolis General Hospital, before and after 
operation according to the technic of Van Slyke, 2 and the change, 
if any, noted. The operations included such major procedures 
as herniotomy, appendectomy, hysterectomy and cholecystectomy. 

The table on page 49 shows the results obtained by Dr. Rose. 

A summary of this table shows that of the 38 patients, 22, or 58 
per cent, showed no decrease in the blood bicarbonate after opera¬ 
tion. 16, or 42 per cent, showed a decrease varying from 1.5 to 
10 volumes per cent, the average decrease being 4.5 volumes per 
cent. In all cases, however, the average fall was but 1.9 volumes 
per cent. 

The table on page 50 will briefly outline the results obtained in 
a later series at St. Mary’s Hospital, showing the nature of the 
cases, the extent of the operation, the amount of anesthesia used 
and the effect on the alkali reserve of the blood. 

From this table it will be noted that there was found a decrease 
in blood bicarbonate in most of the cases with an average drop 
of 4.6 volumes per cent but in none was there a real acidosis 
(below 50 volumes per cent). The average preoperative alkali 
reserve was found to be 68.7 and the average first day postoperative 
64.1. By groups the greatest average drop in alkali reserve of 
the blood was that of laparotomies (6.1), involving cholecystectomy, 
hysterectomy, appendectomy, herniotomy; then the perineal 
group with a drop of 6 volumes per cent; next the genito-urinary 

1 Illinois Med. Jour., No. 1, vol. 41 , p. 6, 

? Jour. Biol. Chem., 1917- 


ACIDOSIS RESEARCH UPON PATIENTS 


49 


TABLE I. 



Amount of 
novocain 
used in cc. 

Carbon 
dioxide 
capacity 
of blood 
before 
operation. 

Carbon 
dioxide 
capacity 
of blood 
after 

operation. 


Decrease 
in volume 
per cent. 

1. Dislocation outer end left 






clavicle. 

90 

63 

65 

63 


2. Chronic endometritis, cyst, 






Bartholin gland 

90 

52 

53 

55 


3. Exophthalmic goiter . 

90 

51 

52 

54 


4. Cholecystectomy .... 

165 

57.5 

51 

52 

6.5 

5. Herniotomy. 

120 

60 

52 

51 

8 

6. Suspension, appendectomy . 

120 

40 

46 

46 


7. Hysterectomy .... 

120 

48 

52 

51 


8. Cholecystectomy .... 

150 

53 

51.5 

52.5 

1.5 

9. Myomectomy, rectopexy 

120 

56 

61 

66 


10. Appendectomy .... 

90 

60 

63 

64 


11. Appendectomy .... 

105 

66 

60.5 

61.5 


12. Appendectomy and suspen- 






sion. 

90 

63.5 

59.5 

61 

4 

13. Nephrectomy. 

75 

62.5 

57.5 

60 

5 

14. Appendectomy and suspen- 






sion. 

90 

72 

67 

69.5 

5 

15. Cholecystectomy .... 

150 

51 

56.5 

54 


16. Prostatectomy .... 

75 

58 

48 

46.5 

10 

17. Appendectomy .... 

120 

65 

65.5 

70.5 


18. Perineorrhaphy, colporrha- 






phy, suspension 

150 

61 

59 

59.5 

2 

19. Dissection of glands of neck 

110 

56 

60 

60.5 


20. Appendectomy .... 

90 

64 

66 

64 


21. Nephrostomy. 

75 

56 

54 

53.5 

2.5 

22. Herniotomy. 

100 

68 

60.5 

66 

7.5 

23. Nephrectomy. 

•75 

55 

50 

51 

5 

24. Hysterectomy .... 

60 

53.5 

51.5 

53 

2 

25. Appendectomy .... 

90 

54 

54 

56 


26. Varicocele. 

60 

57 

59 

57 


27. Herniotomy. 

90 

59 

60.5 

61 


28. Suspension, amputation cer- 






vix. 

120 

56 

56 

59.5 


29. Cholecystectomy, appendec- 






tomy. 

140 

54 

56 



30. Cholecystectomy .... 

120 

52 

50.5 

52.5 

1.5 

31. Gastroenterostomy . 

120 

67 

71.5 



32. Appendectomy .... 

120 

58 

60 

62 


33. Hemorrhoidectomy . 

90 

58.5 

59 

59 

_ 

34. Herniotomy. 

135 

59 

56 

58.5 


35. Suspension, right salpingec- 






tomy, right oophorectomy, 






appendectomy .... 

120 

63 

66.5 

66 


36. Cholecystectomy .... 

150 

56 

56 

56.5 


37. Appendectomy .... 

135 

51 

55 

54.5 

1 i 

• 
























1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 


THE LOCAL ANESTHETICS 


TABLE II. 


Operation and diagnosis. 


Genito-urinary. 

Extraperitoneal !eft ureterotomy 
and transplant of ureter into 
bladder. 

Bilateral hydropyoureter with left 
ureteral stricture, chronic cysti¬ 
tis with atonia. 

Repair of left ruptured kidney. 
Drainage of infected perirenal 
hematoma. Traumatic etiology, 
complicated with contusion of 
abdomen. 

Left nephrectomy. Chronic left 
pyopyelitis with pyelonephrolith- 
iasis; obesity; hypertension. 

Cystoscopy (nephrectomy day fol¬ 
lowing. See previous case). 

Group average 
The Extremities. 

Skin plastic, pedicle flaps over ex¬ 
cised x-ray ulcer right calf region. 

Homogenous skin transplant to 
region of ex cised x-ray ulcer right 
calf region. 

Arthroplasty left elbow with fascia 
lata transplant between resected 
bone ends. 

Chronic infectious anchylosis left 
elbow. 

Excision fibrosarcoma skin left 
thigh. 

Excision subcutaneous fat and ex¬ 
ternal muscle fascis® of medial 
and lateral sides of left thigh and 
leg for elephantiasis. 

Group average 

Perineal. 

Hemorrhoidectomy 

Excision breast tumor (benign). 

Dissection fistula in ano. 

Dissection fistula in ano. 

Perineorrhaphy uterine suspension 
appendicectomy. 

Group average 

Laparotomies. 

Cholecystectomy, drainage; chole¬ 
cystitis, cholelithiasis, chronic 
myocarditis. 

Cholecystectomy, drainage; chole¬ 
cystitis; cholelithiasis. 


Appendicectomy; subacute appen¬ 
dicitis; uterine retroflexion. 




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ACIDOSIS RESEARCH UPON PATIENTS 


51 


table ii. — Continued. 


Case. 

Operation and diagnosis. 

Remarks. 

Novocain 0.7 to 1 per cent, 

No. cc, infiltration. 

Carbon dioxid capacity of 

blood one day preopera¬ 

tive. 

Carbon dioxid capacity of 

blood one day postopera¬ 

tive. 

Carbon dioxid capacity of 

blood postoperative day 

as indicated by number. 



Decrease in C 2 O capacity of 
blood in one day. 

17 

Subtotal hysterectomy; double 


240 

64 

59 

60 2 

64 4 

62 s 

5 

18 

salpingectomy; ovarian resection; 
drainage. Chronic pelvic peri¬ 
tonitis; salpingitis. 
Appendicectomy, uterine suspen- 


210 

70 

64 




6 

19 

sion; perineorrhaphy. 

Uterine retroversion, cystocele, 
rectocele. 

Cecostomy, carcinoma of rectum. 


90 

62 

58 

41 2 

485 


4 

20 

Bilateral herniotomy, inguinal. 


180 

75 

682 




7 

21 

Umbilical herniotomy, lipectomy. 

Very obese. 

120 

72 

58 

683 

70 3 


14 

22 

Bilateral herniotomy (inguinal). 

.... 

150 

78 

68 


. . 


10 

23 

Bilateral herniotomy (inguinal). 

.... 

180 

62 

56 




6 


Group average 

.... 


67.6 

61.5 




6.1 

24 

The Head, Neck and Breast. 

Excision xanthoma of breast. 


210 

68 

622 

52 3 

664 

68 6 

4 

25 

Thyroidectomy, substernal cystic; 
degenerative colloid, left lobe, 
Adenoma, right lobe. 

Dissection neck; carcinoma lower 

Brachial. 

30 

180 

68 

60 

80i 

72 7 


8 

26 


45 

73 

74 

80s 



+ 1 

27 

lip. 

! Chronic infected mastoid from 
bullet wound received twenty 

(Died with-) 
) in 24 hrs. }■ 

90 

68 

66 




2 


years before operation. 

Otitis, mastoiditis, suppurative 
brain cyst and meningitis. Bul¬ 
let removed from right mastoid 
region. 

Group average 

J J 


69.2 

65.5 




3.7 


Grand average preoperative, 68.7. 

Grand average first day postoperative, 64.1. 
Grand average drop, 4.6. 


group with 4 volumes per cent drop; the head, neck and breast 
group with a drop of 3.7 volumes per cent and finally the extremities 
with but 1 volume per cent decrease. This would seem to indicate 
that possibly the type of operation affects the alkali reserve more 
than the amount of novocain used, for no proportionate relationship 
between the amount of solution injected and the decrease of alkali 
reserve could be established. In fact some of the greatest drops 
occurred where comparatively small amounts of novocain were 
used. 

The above table also shows the variability of the alkali reserve 
in some cases as follow-up determinations were made. However, 
in most cases a rapid return to or above the preoperative reading 
is shown. 



























THE LOCAL ANESTHETICS 



The following table indicates the results obtained at the Minnea¬ 
polis General Hospital and shows an average decrease of 3 volumes 
per cent. 


TABLE III. 


Case. 

Diagnosis. 

Amount of 
novocain 
used in cc. 

Carbon dioxid 
capacity of 
blood before 
operation. 

Carbon dioxid 
capacity of 
blood post¬ 
operative day 
as indicated 
by number. 

Decrease in 
volume 
per cent. 

1 

Visceroparietal adhesions 

150 

69.1 

69. U 

0 

2 

Hemorrhoids. 

30 

64.34 

57.62 

/ 

3 

Inguinal hernia. 

90 

61.4 

60.54 

1 

4 

Inguinal hernia, umbilical hernia 

150 

67.2 

69.2 4 


5 

Left inguinal hernia .... 

90 

67.2 

51.0 6 

16 

6 

Right inguinal hernia with forty- 






eight-hour postoperative reten- 






tion. 

90 

65.3 

66.2 


7 

Left inguinal hernia .... 

90 

67.2 

69.1 3 



Grand average preoperative, 65.96. 
Grand average postoperative, 63.24. 
Grand average drop, 3.428. 


As the number of cases studied is relatively small, our con¬ 
clusions must be guarded. However, a comparison of these results 
with those obtained by other investigators 1 working with ether 
would seem to indicate that the decrease in the alkali reserve of 
the blood following novocain anesthesia is less frequent and less 
marked than that following general anesthesia. 

RELATIVE DESIRABLE PROPERTIES OF LOCAL ANESTHETICS. 

A local anesthetic to be efficient must possess certain requisites. 
Most important, it must be very remotely a systemic poison. 
It must not of itself be a cause of pain, either before its action is 
established or after it has ceased. It must be soluble in solutions 
which have approximately the same osmotic pressure as the body 
fluids; that is, the solutions must be isotonic with these fluids. 
It must not be absorbed rapidly from the tissues and therefore 
must be compatible with adrenalin. Its solutions must not deteri¬ 
orate upon boiling. Finally it must be able to paralyze the nerve 
cells in very dilute solutions. 


1 Reimann and Bloom: Jour. Biol. Chem.; 1913, 36, 211; W. S. Carter, Arch. 
Int. Med., No. 3, vol. 26, 319; W. H. Morris, Jour. Am. Med. Assn., May 12, 1917, 
68, 1391. 













DESIRABLE PROPERTIES OF LOCAL ANESTHETICS 


53 


It lias been shown that when the solutions of some of the local 
anesthetics are injected into the tissues, an irritation or burning 
sensation is produced. This is true of cocain, beta-eucain, tro- 
pacocain, stovain, alypin and allocain-S. and quinin. Adrenalin 
may be used with advantage with all except stovain and quinin 
and urea hydrochloride. 

The relative toxicity is perhaps the most important feature 
which must be considered. As has been said before, although the 
large number of compounds which have been introduced as sub¬ 
stitutes for cocain are of a quite diverse chemical nature, they 
simulate one another very closely in their pharmacological actions, 
their differences being chiefly quantitative. When large enough 
doses are given, a severe or even fatal poisoning is produced. This 
has been brought out by Cary Eggleston and Robert Hatcher 1 
of Cornell University. These investigators, after a very careful 
and extensive series of experiments performed on cats, in which 
the toxic symptoms show a close similarity to those produced in 
man, have shown that procain is the least toxic. This result was 
obtained by rapid intravenous injection and the order of the several 
drugs used as to their relative toxicity is as follows: 


Novocain . 

Nirvanin . 

Stovain 
Tropacocain . 
Apothesin 
Cocain 

Beta-eucain . 
Alypin and Holocain 


Mgm. per kgm. 
40 to 45 
30 to 35 
25 to 30 
18 to 22 
20 
15 

10 to 12.5 
10 


These workers also found that “the toxicity of the local anes¬ 
thetics for the cat, after subcutaneous injection, depends upon 
the ratio between the rate of absorption and that of elimination, 
and the local anesthetics can be divided into two classes with 
reference to that ratio. Five, or more than five, times the minimal 
fatal vein dose of alypin, apothesin, beta-eucain, nirvanin, procain, 
stovain and tropacocain can be injected subcutaneously in the 
cat without causing death, while four, or less than four, times the 
fatal vein doses of cocain and holocain similarly injected prove 
fatal.” The drugs of the first group of which novocain is one, are 
eliminated with great rapidity, within a few minutes after their 
injection, by their destruction in the liver. Cocain and holocain 
are eliminated much more slowly. 

Piquand and Dreyfus 2 after intravenous injections of the various 
local anesthetics in rabbits, give the following results: 

1 Jour. Pharmacol, and Exper. Therap., August, 1919, No. 5, 13 , 433. 

2 Cited by M. V. Tyrode, Boston Med. and Surg. Jour., July 7, 1910. 










54 


THE LOCAL ANESTHETICS 


The fatal dose per kilo body weight is as follows: 


Alypin.0.017 gm. 

Cocain.0.0183 gm. 

Beta-eucain.0.019 gm. 

Tropacocain.0.02 gm. 

Stovain.0.03 gm. 

Novocain-epinephrin. 0.046 gm. 

Novocain. 0.063 gm. 


These results, it will be seen, are very similar to those obtained 
by Eggleston and Hatcher. 

To the above table might be added: 

1. Butyn, which as has been mentioned, equals cocain in toxicity 
when given intravenously, but is two and a half times as toxic 
when given hypodermically; and 

2. Saligenin, which has a lethal dose of 0.4 to 1.0 gm. per kilo. 

The relative efficiency of the various local anesthetics is another 

very important feature to be considered in selecting a drug to be 
used. Not a few men have endeavored to determine the degree 
of anesthesia produced by these drugs as compared with that of 
cocain. One of the most careful investigators in this field has 
been Torald Sollmann of Western Reserve University, and his 
contributions are undoubtedly most valuable. He has reached 
his conclusions by using the intradermal wheal method, which 
involves the finest nerve fibrils and possibly the sensory endings. 
The end point or absence of sensation in this method is subjective 
and not very delicate, but he states its accuracy is about that of 
other methods and sufficient for practical purposes. The method 
is regarded as the best for comparing absolute anesthetic efficiency 
and the results obtained are what may be expected in infiltration 
anesthesia. Sollmann V conclusions are as follows: 

“For injection anesthesia, cocain, novocain, tropacocain and 
alypin are about equally efficient. Beta-eucain is one-half and 
quinin-urea is one-fourth as active. Apothesin, antipyrin and 
potassium chloride are one-eighth as active.” 

“ The duration of action of these drugs varies but these differences 
are insignificant when compared with the differences that are pro¬ 
duced by the addition of epinephrin.” 

The experimentation of Piquand and Dreyfus led to the classi¬ 
fication of the different local anesthetics or combinations thereof 
as follows in the order of decreasing strength: 

1. Cocain. 

2. Procain-epinephrin. 

3. Procain, alypin. 

4. Stovain, tropacocain, beta-eucain. 

They conclude that procain-epinephrin is a very active agent 
and next to the least toxic. 


1 Jour. Pharmacol, and Exper. Therap., No. 1 , 11 , 79. 









CHAPTER III. 


THE ANESTHESIA PROBLEM. 

THE PATIENT’S INTERESTS. 

In approaching this subject one must consider primarily the best 
interests of the patient, all other considerations being of second¬ 
ary importance. While the expenditure of the surgeon’s energy 
and time, matters of economy, difficulty of acquiring the necessary 
training, the problem of educating the laity, and many other 
factors may present themselves as more or less objectionable con¬ 
comitants of a method of producing anesthesia, it would seem 
proper to give the patient's welfare precedence over all of these. 

THE CHOICE OF AN ANESTHETIC. 

The patient’s safety is without question the most important 
factor in every case in which it becomes the surgeon’s duty to 
administer treatment; next in importance is the efficiency of the 
treatment to be administered. The patient’s safety is paramount, 
but no anesthetic should be considered appropriate for a given case 
unless it allows the surgeon to carry out the required procedure 
with dispatch and completeness and without embarrassment. 
Efficiency should be insisted upon, and unless an operation can be 
carried out with efficiency under the use of local anesthesia, general 
anesthesia is quite obviously indicated. The one great advantage 
of general over local anesthesia is that under its influence all opera¬ 
tions can be performed. With local anesthesia the performance 
of certain operations is impossible even in the most skilful hands. 
The majority of operations may be carried out with less embarrass¬ 
ment to the surgeon under general anesthesia, but the class of 
operations in which the opposite is true is gradually increasing. 
For instance, the “silent abdomen,” and one might say the “silent 
field’’ in other parts of the body, notably the head, face and thorax, 
under perfect local anesthesia, in many instances give the surgeon 
a marked advantage over the conditions met when general anesthesia 
is used, unless the latter is almost perfectly administered, which is 
perhaps more often the exception than the rule. 

It is agreed by all that certain surgical problems may be best 
solved by the use of local anesthesia. Differences of opinion relate 


5G 


THE ANESTHESIA PROBLEM 


to the scope and variety of problems which may be considered in 
this class. The author believes that these differences are very 
largely the result of a general inadequacy in training and skill in 
proper methods of administration of local anesthesia and in the 
special surgical technic required for its successful use. The advan¬ 
tages accruing to the surgeon skilled in the use of local anesthesia 
are many. Assuming as our premise, that the three main factors 
in the choice of an anesthetic are safety, efficiency and comfort, let 
us take each of these in turn and discuss them in relation to local 
anesthesia. 

Safety.— It will be admitted, I believe, that considered from 
the standpoint of toxicity alone local anesthesia is safer in its 
immediate as well as its remote effects than is general anesthesia. 
This advantage of local anesthesia constitutes its outstanding point 
of excellence, and would doubtless cause its acceptance as the 
anesthetic of choice were it not for its actual and alleged disad¬ 
vantages. The necessity for operative speed is largely eliminated. 
The knowledge that the patient who is inhaling general anesthesia 
is taking a poison into his system, the quantity of which depends 
quite exactly upon the length of time during which he is inhaling 
the drug, must impel the conscientious surgeon to an effort to 
complete his operation with the greatest possible dispatch. As a 
result operative accidents and errors are much more likely to occur 
than they are under local anesthesia, the use of which allows and 
demands deliberation and care, and gives the surgeon an opportunity 
to make careful, methodical, refined manipulations. Its use 
eliminates the element of time as a factor of safety, renders it 
possible for the surgeon to carry out his work with the utmost 
deliberateness, and makes it unnecessary that all operations be 
concluded in the shortest possible time. The elimination of the 
necessity for haste makes it possible to place clamps and ligatures, 
perfect dissections, complete the toilet of the peritoneum, and to 
perform many other technical manipulations with much greater 
care and efficiency than is possible when working at top speed. 
There can be no doubt that a method of anesthesia which reduces 
the necessity for haste adds to the safety of the patient who is 
undergoing an operation. 

Efficiency.— In a comparison of methods it is assumed that the 
performance of an efficient operation will be made possible without 
suffering on the part of the patient and without embarrassment on 
the part of the surgeon. The efficiency of local anesthesia, or, in 
other words, the opportunity offered the surgeon to carry out the 
various surgical procedures by its use, is the subject of great diversity 
of opinion and varies to such an extent in the judgment of different 
surgeons that few are agreed as to the position the method should 


THE CHOICE OF AN ANESTHETIC 


57 


occupy. 1 he results obtained from its use depend very largely 
upon the skill and training of those who essay to use it—skill and 
training which embody not only a knowledge of the principles and 
practice of inducing anesthesia, but also a knowledge of, as well as 
the ability to apply, the special surgical technic which must be 
employed in order to operate successfully under this form of anes¬ 
thesia. Those who have concentrated upon the use of local anes¬ 
thesia and have developed a fair degree of skill in the method of its 
administration and in the proper methods of operating under its 
use, have presented sufficient evidence to make clear the fact that 
a fairly large percentage of surgical operations may be efficiently 
performed by the use of this method. 

It would seem that the time has arrived for surgeons to take stock 
and to make a sincere attempt to ascertain the facts in relation to 
the anesthesia problem. If the element of safety is best assured by 
the use of local anesthesia, and the protection which is the right of 
every surgical patient is withheld because the surgical profession in 
general through lack of training is unable to use the method effici¬ 
ently, this training and skill must be more widely disseminated 
throughout the surgical world. Sufficient evidence is at hand to 
demonstrate that with increased experience every surgeon may 
rapidly broaden the scope of local anesthesia in his own practice 
and bring its advantages to an increasing number of patients. 

At the present time many surgeons with practically no training 
whatever consider themselves equipped to perform operations under 
local anesthesia. The author has in his possession hundreds of 
letters from physicians, in which he is asked for information regard¬ 
ing the local anesthesia technic for the performance of some particu¬ 
lar operation. In these letters of inquiry the inquirer usually adds 
that he has a patient upon whom he intends to operate presently, 
and is therefore desirous of obtaining this information. Even 
surgeons of repute often have only a limited knowledge of the use 
of local anesthesia. These same men wrnuld without doubt freelv 

*j 

admit that none but the most perfectly trained experts should be 
allowed to administer a general anesthetic, yet without any special 
training or experience in the use of local anesthesia, they appear 
to be quite willing to proceed to use it upon their patients. Until 
this attitude changes we must expect to have the efficiency of the 
method assailed. As the efficiency of the method depends upon the 
surgeon’s training and skill in its use, it would seem fully as incum¬ 
bent upon all surgeons to prepare themselves for the efficient 
administration of local anesthesia in all cases in which its use is of 
advantage to the patient as it is to furnish a skilled anesthetist to 
every patient requiring a general anesthetic. If this standard is 
met, the author is convinced that the sum total of instances in which 


58 


THE ANESTHESIA PROBLEM 


local anesthesia is the method of choice will exceed that in which 
anesthesia by inhalation is plainly indicated. 

Comfort. —Comfort, though of less importance than safety and 
efficiency, is yet of sufficient moment to merit the attention of every 
surgeon, and anything which may contribute to lessen the disagree¬ 
ableness of surgical operations and their sequelse should not be 
overlooked or neglected. This phase of the subject presents many 
angles for one’s consideration. One must think of the psychic as 
well as of the physical discomforts which a patient must undergo; 
and, as these discomforts vary both in kind, duration and intensity, 
the total or combined effects of all of the disagreeable features 


connected with the treatment of an individual should be considered 
in drawing conclusions, rather than the effects to be endured or 
eliminated during the limited period of the actual operation. 

An analysis of the causes of discomfort connected with surgical 
operations will show that in all cases in which local anesthesia is at 
all applicable, it is the method of choice from the standpoint of 
comfort, provided only that it is properly administered and accom¬ 
panied by the correct operative technic. 

Discomfort connected with a surgical operation may be divided 
into three well defined stages or periods: (1) The period before the 
operation (when the suffering is largely psychic in character); 
(2) the period of discomfort during the performance of the opera¬ 
tion; and (3) the period of postoperative discomfort. 

Apprehension is the greatest cause of the suffering which precedes 
the operation and this may be greater with one form of anesthesia 
than with another. However, the possible suffering of a patient 
from apprehension regarding anesthesia may be more than offset 
by the assurance that comes from the belief that the method of 
anesthesia to be employed offers advantages over other methods 
in safety, efficiency and postoperative comfort. This assurance 
may also more than compensate for the mental discomfort accom¬ 
panying the performance of an operation upon a conscious patient. 
To the average patient the thought of postoperative discomfort 
is often more distressing than the thought of the operation itself, 
but to many surgeons postoperative discomfort is considered the 
inevitable and necessary concomitant of a surgical operation. These 
surgeons therefore minimize or entirely ignore the patient’s very 
real physical distress following an operation under general anes¬ 
thesia, while at the same time they place great emphasis upon the 
mental suffering resulting from apprehension and upon the possi¬ 
bility of pain incident to the performance of an operation under 
local anesthesia. Thus it is suggested, when comparing the relative 
merits of the different forms of anesthesia in relation to comfort, 
that not one or the other advantage or disadvantage should be 


THE CHOICE OF AN ANESTHETIC 


59 


overemphasized, but that the sum total of comfort or suffering 
connected with a surgical operation should be considered. 

The actual suffering which a patient must undergo during the 
performance of an operation under local anesthesia will depend 
upon a number of factors. He is confronted with certain disturbing 
anticipations. He has many things to consider regarding the 
ordeal through which he is to pass—the danger to his life, the 
possibility of failure to obtain a cure and the probability of a period 
of great pain and discomfort following the operation. His mental 
discomfort will depend upon his temperament, his confidence in 
his surgeon and his faith in his surgeon’s methods. The stronger 
his faith, the less will be the mental torture and ‘‘psychic incom¬ 
patibility” caused by his apprehension; whereas the weaker his 
faith, the greater will be his suffering before and during the opera¬ 
tion. The apprehension which results from lack of faith serves also 
to exaggerate and intensify the actual physical suffering that the 
patient is compelled to undergo during the operation. This subject 
will be further elaborated under a discussion of the psychic aspect 
of the surgical case, but I deem it of sufficient importance to discuss 
it in considering the elements which may have a bearing upon the 
patient’s comfort. 

We know that without faith the slightest needle prick, or even 
the contact of a gauze sponge with the skin may cause certain 
patients considerable pain, whereas the establishment of confidence 
and a cooperative spirit in a candidate for operation may and indeed 
does bring about an attitude which makes it possible for the patient 
actually to discount any physical pain which may be produced 
during the introduction of the anesthetic or during the performance 
of the operation. It follows therefore, that the establishment of 
this faith or feeling of confidence in the mind of the patient is one 
of the prime requisites for doing satisfactory work under local 
anesthesia. How this faith is to be established is an important 
question. Undoubtedly the most important single factor in its 
speedy establishment will be the routine performance of local 
anesthesia operations without the production of unnecessary pain. 
Conversely the longer surgeons insist upon inflicting avoidable 
suffering upon their patients during operations attempted under 
the use of local anesthesia, the more tardy will be the dissemination 
of faith among prospective patients. It is the writer’s conviction 
that the use of proper methods of introducing anesthetic solutions 
into the tissues combined with an appropriate surgical technic and 
the judicious addition of general anesthesia in all cases in which an 
operation begun under local anesthesia cannot be completed without 
pain, if sufficiently widely adopted by the surgical profession, would 
rapidly reduce to a minimum the mental and physical suffering 


60 


THE ANESTHESIA PROBLEM 


which a percentage of patients must now endure before and during 
operation. 

Postoperative discomfort , while due to a wide variety of causes and 
varying with the condition of the patient and the operative pro¬ 
cedure employed, can without question be alleviated by modifica¬ 
tions of the methods which are to a large extent definitely under the 
control of the surgeon. The amount of postoperative discomfort 
following any particular operation will reflect to a marked degree 
the manner in which the procedure has been carried out. Exhaus¬ 
tion from trauma due to severe traction and extensive handling of 
organs, exposure of the tissues, hemorrhage, prolonged or poorly 
administered anesthesia by inhalation, will with absolute certainty 
be followed by an increased amount of postoperative suffering in 
the majority of cases. Postoperative thirst, nausea and vomiting, 
the prolonged taste of noxious gases, intestinal distention, back 
strain, and the suffering due to such complications as bronchitis and 
pneumonia, all contribute to increase the sum total of the surgical 
patient’s postoperative discomfort. 

The convalescence of the patient will depend somewhat upon the 
anesthetic used, the manner of its administration and the manner 
in which the operation is done. Unskilful work will be reflected 
not only by increased postoperative discomfort, but also by other 
disagreeable sequelae, such as delayed convalescence, an increased 
hospital bill, increased nursing expense and increased expense 
incurred by the patient’s relatives, who may deem it necessary to 
remain in the vicinity of the afflicted one during his sickness. Thus 
delayed convalescence must be added to the sum total of the 
discomforts which a patient must undergo. We must therefore, 
when considering the choice of anesthesia, reckon with this factor 
as well as with others. It is impossible to measure the aggregate 
discomfort which patients may suffer from postoperative complica¬ 
tions alone. 

After-pain .—Hertzler states that the use of novocain solutions 
in the tissues is productive of an increased amount of wound pain 
following operation. As his experience did not coincide with that 
of the author a series of experiments were carried out in an effort 
to determine, if possible, the facts in relation to postoperative wound 
pain. 

The impression of the author had been that patients were much 
more comfortable after an operation under local anesthesia than 
where general had been used, although the fact that there was no 
loss of consciousness allowed them to appreciate wound pain earlier 
when local anesthesia was employed. Therefore a number of 
patients who were operated upon under general anesthesia, for 
conditions requiring bilateral operations (bunions, hernia, etc.) 


SPECIAL ADVANTAGES OF LOCAL ANESTHESIA 


61 


were injected. In these eases novocain-adrenalin solution was 
injected in one side and the other used as a control. The amount 
of after-pain complained of showed no difference in the two sides. 
About one-third of the patients presented an equal amount of pain 
on the two sides, one-third complained more of the side which had 
been injected with the solution, and one-third complained less of the 
injected side. Therefore it was concluded that novocain solutions 
per se are not the cause of increased wound pain. 

SOME SPECIAL ADVANTAGES OF LOCAL ANESTHESIA 

DURING OPERATION. 

One of the most important qualities of an anesthetic rests in the 
opportunity it offers the surgeon for carrying out an operation under 
the most favorable conditions. No other anesthetic can present 
the so-called “silent field’’ with the degree of perfection possible 
under local anesthesia. The absence of forced or variable respira¬ 
tory excursion; the flaccidity of the muscles whose reflexes should 
be completely abolished by local anesthesia; the absence of local 
engorgement of the circulatory system; the advantages offered by 
the cooperation of the patient which is so helpful when it is desirable 
to demonstrate the hernial sac, the gall-bladder, the surface of the 
lung, the mucosa of the rectum, the vagina, or the oral cavity; 
the ability to use the vocal cords; the production of pain by the 
manipulation of an organ in an effort to reproduce the painful 
sensations of which the patient previously complained, are all of 
decided advantage to the surgeon when operating upon the conscious 
patient. 

What for instance could give one more satisfaction than the 
cheery “Good morning” of the patient who is undergoing a thyroid¬ 
ectomy, when uttered between the time of clamping and sever¬ 
ing the tissues in the region of the recurrent laryngeal nerve? 
Compare the opportunities for dissection of the lateral region 
of the neck under the two methods of anesthesia. With general 
anesthesia it is not uncommon to find the internal jugular vein 
distended to the diameter of one’s thumb, while under local 
anesthesia this vessel may be distended or allowed to collapse 
practically at the patient’s will. In fact, under local anesthesia, 
venous hemorrhage is largely under the control of the patient. 
In abdominal work the absence of engorgement of the local circula¬ 
tory system not only greatly aids in reducing hemorrhage but offers 
even more assistance in presenting to the surgeon organs in which 
the blood supply is decreased to such an extent that they may be 
manipulated and operated upon with satisfying facility. The 
presence or absence of marked respiratory excursion which is under 


62 


THE ANESTHESIA PROBLEM 


the control of the will of the patient also gives the surgeon a decided 
advantage when operating under the use of local anesthesia. This 
relates not only to operations upon the brain, neck, thorax, rectum 
and vagina, but also upon the bladder and especially upon the 
intraperitonea 1 viscera. The “negative” intraperitoneal pressure 
which presents when the abdomen is opened under local anesthesia 
offers an opportunity to observe the tissues and to carry out opera¬ 
tive procedures under conditions which are almost ideal, (Fig. 202, 
page 473 and Fig. 215, page 493.) 

When demonstrating this the term “autopsy operation” suggests 
itself, because the conditions presented closely resemble those 
found at autopsy upon the fresh cadaver. The flaccid organs lie 
in their normal positions and may be examined and manipulated 
at will provided the manipulation does not exceed certain bounds. 
In addition, the cooperation of the patient makes it possible to 
maintain the organs in an absolutely quiescent state for a reasonable 
period of time. If desired, the patient may at will extrude certain 
viscera into the operative field (Fig. 196, page 449). This attribute 
of local anesthesia is of use especially in dealing with the stomach, 
gall-bladder and in hernia operations. The orthodox introduction 
of gauze packs for the forcible removal of the small intestine from 
the pelvis, in removing the appendix and in many other intra¬ 
peritoneal operations is not only unnecessary but of no advantage to 
the surgeon when using local anesthesia, and is exceedingly undesir¬ 
able from the standpoint of the patient’s best interests. The less 
trauma inflicted upon the intra-abdominal viscera in this manner 
the better for the patient. The proper use of local anesthesia 
combined with strategy will in a large percentage of cases allow one 
to make the necessary displacement of the intra-abdominal viscera 
without the use of the gauze pack forced home by the surgeon’s 
strong right arm. In septic conditions within the abdomen the 
excursion of the viscera during and after operation is undoubtedly 
often the cause of the dissemination of septic material into uncon- 
taminated fields. Here the use of local anesthesia offers the best 
opportunity for the reduction of this excursion and as a result the 
tendency toward further spreading of peritonitis. In another 
portion of this work the subject of dissemination of septic material 
about the abdominal cavity as a result of forced respiratory excur¬ 
sion and especially on account of postoperative vomiting which 
under local anesthesia is reduced to a minimum, is discussed at 
greater length. Suffice it to say here that the author believes that 
spreading infection after operation may be minimized by the use of 
local anesthesia. 

The reduction of trauma to the lowest point compatible with the 
performance of an operation is best effected by the use of local 


ADVANTAGES BEFORE AND AFTER OPERATION 63 

anesthesia. The deliberation in operating which is demanded and 
allowed, the careful handling of tissues which is so desirable, the 
conditions requisite for the employment of feather-edge dissection, 
and the elimination of the necessity of forcing the viscera about by 
the use of sponges, with the well-known effect which the need for 
the avoidance of trauma has upon the surgeon and his enhanced 
respect for tissues when he is working under local anesthesia, all 
offer advantages to surgical patients which cannot be overestimated. 
For the realization of this, local anesthesia is largely responsible. 
The demand that it makes in this regard, as well as the opportunity 
it offers for operative finesse, cannot fail to result in that improve¬ 
ment of surgical technic, which the best interests of the patient 
requires. 

ADVANTAGES BEFORE AND AFTER OPERATION. 

While the advantages just enumerated relate especially to the 
period of the operation itself, and while many others might be 
mentioned; the use of local anesthesia also presents attributes of 
advantage to the patient during both the preoperative and post¬ 
operative periods. 

With this method preoperative starvation is usually unnecessary, 
the withholding of either solid or liquid food not being so necessary 
where this form of anesthesia is to be used. The patient and his 
friends may be assured that an operation under this method offers 
the greatest safety that it is possible to give; that during the same 
time the amount of actual labor and perspiration that he will have to 
put forth will be negligible; that there will be absence of struggling; 
that there will be no bodily trauma such as joint dislocation, sacro¬ 
iliac subluxation, back or muscle strain, nerve pressure, injury to 
the eyes, or to the tongue, swallowing of teeth, burning from hot- 
water bottles and traumatization by attendants who only too 
frequently are careless in handling anesthetized patients. He 
may have the additional assurance that following the operation 
there will be decreased danger from the after effects of the operation 
and from the anesthetic; that his heart, lungs, liver and kidneys 
will be taxed to a lesser degree after local than after general anes¬ 
thesia; that the amount of postoperative nausea, vomiting, gas 
pains, and general depletion will probably be less marked; that the 
wound strain and pain consequent upon retching and vomiting 
will be practically eliminated; that the probability of death, 
immediate or remote, from the effect of local anesthesia is almost 
nil, that the postoperative discomfort resulting from thirst will be 
reduced to a minimum; that his dressings and wounds will not be 
soiled by vomitus; that he will not fall out of bed during recovery 


G4 


THE ANESTHESIA PROBLEM 


from the anesthetic; that infectious processes will not be unduly 
disseminated by muscular activity and Vomiting; and that intra- 
peritoneal infections will not be spread by visceral excursion, result¬ 
ing from the retching, vomiting and struggling during and after the 
induction of anesthesia. In addition he will have the satisfaction 
of knowing that by this method the surgeon had been offered the 
opportunity to perform the operation in as efficient a manner as is 
possible. Incidentally, he may obtain some satisfaction from the 
knowledge that the surgeon whom he has employed is the one who 
performs his operation, and that it has not been detailed to some 
assistant who was not his choice. He may also learn something 
of the decorum of the operating room, and have removed prejudices 
which his mind may have harbored regarding the sincerity or 
seriousness of those who take part in the operation. 


THE ATTITUDE OF THE PATIENT IN RELATION TO LOCAL 
ANESTHESIA AND UPON WHAT IT DEPENDS. 

Patients vary greatly in regard to their attitude toward physicians, 
hospitals and surgical operations. Much may depend upon the 
temperament, nationality, age, sex, general intelligence, and medical 
intelligence, but aside from certain social types with which we must 
always reckon, the greatest influence upon the patient under local 
anesthesia is exerted through his intelligence and previous training. 

It has been my observation that those patients who are in a 
position to estimate judiciously the merits of local versus general 
anesthesia have in a large percentage of cases decided in favor of 
the local method. I refer to individuals who have been operated 
upon one or more times by each of the methods. Those deciding 
in favor of general anesthesia were usually in the class that had 
been caused pain during operations under local anesthesia. Many 
of these, after further experience with general anesthesia, expressed 
a preference later for the local method. While appreciating the 
fact that it is extremely difficult to evaluate properly the merits 
of any method when judged purely from the standpoint of the 
patient’s choice, on account of the great variety of factors which 
enter into the formation of the patient’s opinion, extended experience 
and a careful collection of data allows one to form impressions which 
may be of more or less value. The opinion of the patient may vary 
with the length of time that has elapsed since the operation. For 
instance, the patient who has complained of one or more kinds of 
discomfort, before, during or after operation may upon reflection 
be extremely friendly to the particular form of anesthesia used. On 
the other hand, a patient who has not shown the slightest outward 


THE ATTITUDE OF THE PATIENT 


65 


sign of discomfort during the same relative period may, upon 
mature reflection, decide that some other method would have been 
more acceptable. Again, the associations of the patient either 
immediately or remotely following an operation may be such that 
a favorable verdict will be withheld on account of prejudices engen¬ 
dered by the unfavorable comment of those with whom he has come 
in contact. One must take all of these matters into account in 
making an eflort to arrive at proper conclusions. Averages only 
are to be considered, and those only after the most careful investiga¬ 
tion of a comparatively large number of cases. 

In the crystallization of the lay opinion with regard to this 
subject there are therefore three important factors which are 
of influence: (1) The degree of physical discomfort which the 
patient is compelled to undergo—a matter which is largely 
under the control of the surgeon and the hospital corps; (2) the 
environment of the patient before, during and after operation, a 
factor which may be influenced to some extent by those who have 
the patient’s treatment in charge, but which is to a large extent 
educational and dependent upon the dissemination of propaganda 
which is favorable to the method; (3) a factor which presents 
itself to a more limited degree, namely, the temperament, or mental 
make-up of the patient. The vast majority of patients who are 
psychically incompatible with the local method are made so by the 
antilocal attitude which permeates the medical as well as the lay 
mind, although there are undoubtedly a few individuals who are so 
constituted that even under the most favorable auspices they can¬ 
not possibly accept the local method with enough poise to eliminate 
psychic disturbances which are sufficiently grave to offset the 
advantages of local anesthesia. Here again, we must reckon with 
the law of averages, and the greatest good to the greatest number 
must be our criterion in arriving at a decision. 

The surgeon who in this day and age fails to take into account 
and to attach the full importance to the psychic elements relating 
to the care of his patients must be considered in a category with 
those who are withholding from their clientele an important and 
necessary adjunct to treatment, even though they are at the same 
time administering a fair measure of well directed treatment. The 
patient’s comfort may be largely dependent upon attention to this 
feature and response to treatment is also dependent upon it. Too 
frequently the patient is considered a “case” and the surgical 
condition is treated from the mechanical standpoint alone, while the 
fact that the patient is a complex organism with a mental as well as 
a physical aspect is often lost sight of. People vary to as great an 
extent in relation to their mental make-up as they do in relation 
to the variety of surgical lesions which they present. Mental 


66 


THE ANESTHESIA PROBLEM 


states bordering upon insanity are not uncommon and even the 
insane present surgical lesions which may or may not be a causative 
factor in their mental derangement. A composite picture must be 
very definitely drawn of each case in order that the surgeon may 
institute appropriate therapy and as a rule the surgical therapy 
must be accompanied by constant attention to the psychic aspects 
of the case. It is generally recognized that one who is afflicted with 
a physical ailment is apt to be below par mentally. 

The question of anesthesia presents itself as one of,the factors 
with which the patient must cope and the foregoing remarks apply 
as well to one form of anesthesia as to another. 

General Intelligence of the Patient.—The educated, refined, 
sensitive patient, even of the neurotic type, is one of the most 
amenable to the method. On the other hand, the dull, poorly 
educated and otherwise stoical individual is apt to be more 
suspicious, less willing to obey instructions, much less amenable to 
reason and therefore more subject to “psychic incompatibility.” 
It is significant that from the psychic standpoint the author’s work 
has proven more successful in the care of private patients than in 
his service at a charity hospital. 

The Psychic Aspect of a Surgical Case.—The greatest factor in 
reducing the fear and worry incident to the use of local anesthesia 
is a knowledge on the part of the patient that the operation is to be 
a painless procedure. If, in addition, he can be made to understand 
the many other advantages of the method the result is often the 
antithesis of what one might anticipate; the patient enters into the 
spirit of the thing and actually tries to appear to the best possible 
advantage. At best the undergoing of a surgical operation is an 
exceedingly unpleasant experience, and in making comparisons 
between methods we can only argue that one method is more 
disagreeable or less disagreeable, as the case may be, than some 
other. For instance a person who has had an unfortunate experience 
with one method is ready on this account to accept any other 
method. Thus large numbers of patients who have had unsatis¬ 
factory experiences with general anesthesia are very easily brought 
into line for the administration of local anesthesia. This otherwise 
most desirable force is however, largely offset by the fact that 
local anesthesia as usually employed allows the patient no alterna¬ 
tive but to support general anesthesia in the future. Without doubt 
the spectacle so often seen of the struggling, squirming patient with 
all muscles contracted, “the veins standing like whipcords upon his 
brow,” while he squeezes an attendant’s hands with all his might 
and begs his surgeon to have mercy, while the latter, not knowing- 
how to give local anesthesia successfully, is frantically substituting 
that worthless commodity “vocal” anesthesia—may be responsible 


THE ATTITUDE OF THE PATIENT 


67 


for the fact that the inroads of local into the field of general anes¬ 
thesia are not greater. 

As the greatest element in the reduction of psychic trauma is 
the education of the surgeon as well as the patient, improvement 
along this line is certain to take place and psychic trauma will 
largely disappear as the method is more universally adopted. This 
is sure to follow if it is made more worthy of adoption. Local 
anesthesia has been laboring under a handicap on account of its 
complete or partial failures and on account of the ignorance of the 
laity concerning its many advantages. As soon as the laity has an 
opportunity to unlearn the untruths taught by the medical profes¬ 
sion regarding it the use of the method will become more general. 
Already a sufficiently large variety of operations are being success¬ 
fully performed under its influence to make a profound impression. 
When the fact becomes established that complaints of pain by the 
patient are usually direct and positive evidence of inefficiency on the 
part of the administrator of the anesthetic, and not in any manner 
to be construed as a shortcoming of the anesthetic per se, we may 
expect to see the psychic element assume a much less important 
role. The time is fast approaching when men will be ashamed to 
admit that they cannot perform certain operations painlessly under 
local anesthesia, when other surgeons are doing them so regularly 
and consistently. The excuses now offered to inquiring patients when 
surgeons are requested to do operations under local anesthesia 
should not prevail. While the medical profession is slow to change 
from old and well established methods the laity is not slow in 
demanding changes provided they believe these changes represent 
an improvement. 

Assuming that the proper technic is to be used and that the 
surgeon is to perform a comparatively painless operation, much 
may be done and indeed everything possible should be done to aid 
the patient in meeting the ordeal. This psychic aid begins with 
the first visit of the patient and continues as long as he is under 
treatment. The attendants should have constantly in mind the 
welfare of all prospective surgical patients and begin the preparation 
at once. The deportment of the office force, the nurses, the interns, 
surgical assistants and the surgeons is of the utmost importance. 
The details of preparation will appear in another chapter but I 
would here emphasize the fact that no effort should be spared to 
remove every possible cause of irritation and to handle the patient 
in such a manner as to gain his confidence. The manner of giving 
a bath or an enema at the beginning of the sojourn in the hospital 
may largely influence a patient. Errors of the attendants in any 
part of their work may be the means of putting the patient in a 
mood which is incompatible with the calm, placid quiescence which 


G8 


THE ANESTHESIA PROBLEM 


is sought. Bathing a patient with water of a temperature which is 
disagreeable to him, placing him upon a cold bed-pan, shaving the 
abdomen with a dull razor and a score of similar errors may serve 
to upset the hypersensitive individual who too often feels that he is 
already the victim of sufficient trouble. 

As a rule all preparations should be made as long as possible before 
the operation and everything should be done to bring the patient’s 
mind into a tranquil state. This may best be accomplished by 
attention to such details as those mentioned above. The tactful 
answering of the patient’s questions is also an important element. 
A good rest the night preceding the day of operation and the absence 
of company and “fussing” upon the morning of the operation are 
conducive to the patient’s interests. A liberal amount of fluids and 
in some cases even a limited amount of solid food are desirable 
supportive measures. During the journey to the operating room, 
roughness while transferring the patient from the bed to the cart 
or from the cart to the operating table, which may cause needless 
suffering, should be avoided. The conversation, if any, carried on 
in the operating room should be such as is calculated to inspire 
confidence. The din of metal instruments and basins, exposure to 
too great cold or heat, the application of irritating lotions to sensitive 
skin areas, an uncomfortable position upon the table, constriction 
of any part by tight strapping, the sudden application of cold or 
hot solutions to the skin, especially if made without warning, strong 
light reflected into the eyes, careless draping—for instance, allowing 
a sheet to fall over the patient’s face and perhaps to remain there 
until complaint is made—itching of the nose, thirst, fear of falling 
off* the table, exposure of the genitalia, and a host of other annoying 
factors must be anticipated and met by appropriate measures. 
In short, the whole chain of attendants should be on the qui vive, 
but exert every effort to prevent the patient from being in the same 
condition. The machine should run so smoothly and the team¬ 
work should be so perfect that no feeling of the tenseness which 
naturally exists is transmitted to the patient. 

The Question of Discussing the Form of Anesthesia with the 
Patient.— For a number of years it was the author’s practice to 
spend considerable time with each patient discussing among other 
matters the merits of local anesthesia, when going over the questions 
which have to be threshed out after deciding that an operation is to 
be performed. Whether or not it is advisable to discuss at length 
this phase of the subject with a prospective patient or his friends 
is an open question. Increasing experience has led to the belief 
that the better plan is to allow the patient to understand that this 
detail, like all others connected with the operative procedure, should 
be left to the surgeon who is in charge of the case. Some patients, 


THE ATTITUDE OF THE PATIENT 


69 


of course, demand a discussion of the anesthesia. When asked con¬ 
cerning the method to be used, the author usually replies that he 
knows more about this particular subject than the patient can hope 
to know, as he has studied it and thought about it for many years, 
and that if the patient is willing to place himself in the hands of the 
surgeon for the performance of an operation he ought to be willing 
to allow him to use his own judgment regarding this point. The 
patient is then assured that every effort will be made to furnish 
him the greatest protection and comfort possible. This preliminary 
line of argument will usually bring out the patient’s preconceived 
notions and one can then act accordingly. Should the patient be 
“prolocal,” only a few words are necessary to clinch his confidence; 
if “antilocal,” arguments may be used setting forth the well- 
known advantages of the method although these arguments do not 
as a rule increase the confidence of the patient. At least this has 
been the author’s experience. Much more efficient is the state¬ 
ment that the patient may have general anesthesia if he so desires, 
but that he had better leave the matter to his surgeon. A much 
better plan and one which is calculated to develop the maximum of 
confidence and faith on the part of the patient is to introduce a 
former patient who has undergone an operation successfully by 
the local method. This procedure is the most satisfactory known 
and should the former patient voluntarily recommend the method 
—that is, without coaching on the part of the surgeon—the effect 
of this spontaneity and sincerity is quite sure to make a favorable 
impression. Should the operations happen to be of the same 
general nature the matter is usually settled beyond question. The 
success attending this method has been so universal that one may 
feel assured that the introduction of local anesthesia into all fields 
will not be greatly interfered with by the psychic incompatibility 
of patients. The length of time demanded for its more universal 
adoption will depend only upon the manner in which it is applied. 
The patient himself will be the medium through which propaganda 
favorable to the use of local anesthesia will be distributed. 

The Necessity of Attention to Psychic Aspects by Attendants. 
The personnel of the staff* whose duty it is to carry out the pro¬ 
cedures which are necessary in relation to the making of the diagnosis 
and the treatment of surgical patients should have these considera¬ 
tions constantly in mind. From the time the patient presents 
himself until he is discharged each person associated with his 
treatment should be well schooled not only in his duties in regard 
to the refinements of diagnosis and surgical treatment but in addi¬ 
tion should as nearly as possible approach automatism in the proper 
attention to the psychic aspect of the case. Even under conditions 
where the surgeon himself has not the time to give attention to 


70 


THE ANESTHESIA PROBLEM 


detail to each patient the morale of his corps of assistants should 
be such that the amount of mental as well as physical trauma and 
suffering may be reduced to the minimum. 

While there is no adequate method of estimating the amount of 
pain or anguish suffered by a patient while undergoing diagnosis and 
surgical treatment, the estimation of this factor being largely a 
matter of judgment on the part of the observer, there is no doubt 
that with proper effort much may be done to reduce the patient’s 
suffering. The dread of what is to happen would seem to be almost 
as great a cause of anxiety as the actual suffering which is to be 
experienced. If this is true, is it not possible greatly to reduce 
this factor by the expenditure of properly directed effort? A 
failure to appreciate the necessity of making the ordeal as pleasant 
as possible has in the past caused patients a great deal of unnecessary 
suffering. Obviously surgical treatment must necessarily be 
accompanied by pain and discomfort and a knowledge of this fact 
contributes largely to the anguish of anticipation in each case. 

“PSYCHIC SHOCK.” 

What effect the mental attitude of a patient has and what part 
it plays in the bringing about of that condition universally known 
as surgical shock is still a mooted question. The condition known 
as shock, though imperfectly understood from an etiological stand¬ 
point, is rather easily recognized, and the numerous factors which 
produce it are comparatively well known. Among these factors 
fear must undoubtedly be considered, the prominence it assumes 
depending largely upon the judgment of the individual observer. 
Crile and many others believe that the psychic element is extremely 
important among the factors that bring about this condition of 
depression of the vital forces. While it is undoubtedly true that the 
depressant effects of fear are obvious in a certain percentage of 
surgical cases and while their elimination is desirable, the writer 
is under the impression that this factor has been greatly exaggerated 
when offered as an argument against the use of local anesthesia. 
A consideration of this subject must take into account the various 
factors upon which fear in a patient is based. The three main causes 
of fear in the prospective patient are: 

1. Fear of the outcome following operation. 

2. Fear or dread of the disagreeableness connected with the 
ordeal. 

3. An unreasoning fear or dread of an operation in an individual 
who may fear neither death nor the disagreeable effects of an 
operation. 

Now, should a patient be placed in either of the first two classes, 


71 


[PSYCHIC SHOCK 

or in both, as lie usually is, why should there not be a lessening of 
the fear of a fatal outcome, provided the patient knows that local 
anesthesia is more safe than is general anesthesia? Again, if a 
patient be grouped in (lass 2 and dreads the disagreeable effects 
connected with an operation, why should there not be a lessening 
of the psychic shock resulting from fear, provided the patient 
knows that the amount of suffering will probably be less than he 
would experience if a general anesthetic were used? x4 careful 
canvassing of the situation for many years has convinced the 
writer that the dread of the loss of consciousness is the most objec¬ 
tionable element connected with an operation. The possibility 
that he may not recover from the anesthetic is always before a 
patient’s mind. Also the realization on the part of the patient 
that he is to be relieved to a large extent of the postoperative 
sequelae of general anesthesia, to-wit: thirst, nausea, vomiting, gas 
pains, wound-strain, kidney or lung irritation, and so forth, has a 
markedly reassuring effect and is largely responsible for the absence 
of psychic shock in these patients, although the opposite is supposed 
to be true. 

The fact is that a vast majority of patients do worry at the 
approach of an operation but experience with some thousands of 
cases under each form of anesthesia has convinced the author that 
the odds are in favor of local anesthesia by a wide margin. This 
margin will be greatly increased in the future, as the technic of 
local anesthesia improves and as patients realize more fully the 
greater comfort, ease and safety with which a large percentage of 
operations may be performed under local anesthesia. This realiza¬ 
tion will greatly reduce the number of patients in Classes 1 and 2, 
and even Class 3 will diminish as the horror of operations decreases 
in the minds of the laity. Indeed, the large inroad that local 
anesthesia is making into the field of general anesthesia is a potent 
cause in the reduction of the number which may be so classified. 
Notwithstanding all this, there will remain individuals who ask 
to be relieved temporarily of their mental processes and to have their 
operations done under general narcosis. The members of this 
class undoubtedly suffer from some degree of psychic shock and 
many of them might be operated upon under general anesthesia 
with less depression than would attend the use of a local anesthetic. 
The choice of anesthesia must rest with the judgment of the surgeon 
but in no case should the surgeon force local anesthesia upon a reluc¬ 
tant patient. 

In previously published articles the author has stated that our 
patients may to some extent be educated to any particular form of 
anesthesia. One has only to observe the different methods used in 
the various large clinics and to talk with patients who have been 


72 


THE ANESTHESIA PROBLEM 


there in order to realize that though the various methods are 
extremely diverse and some, at least, are somewhat antiquated the 
patients are fairly well satisfied and willing to defend the method 
that has been used upon them. Such is the plasticity of the human 
mind. The patient is easily taught that a certain kind of anesthesia 
is superior to all others and a satisfactory experience makes him a 
staunch propagandist. It is only a matter of proper dissemination 
of the facts. A proper use of local anesthesia will bring this about; 
while the abuse of the method, which is altogether too widespread, 
will delay it somewhat. 

PRELIMINARY NARCOTICS. 

Narco-local Anesthesia (See Chapter V, page 132).—Much 
has been written for and against the practice of giving some drug 
or combination of drugs to the prospective patient before the 
administration of anesthesia for the performance of an operation. 
Various objects have been the aim of those who have resorted to and 
have supported this practice. As a rule, preliminary doses of 
hypnotic drugs are used for the purpose of bringing the patient to 
the ordeal through which he must pass with the senses somewhat 
blunted in order that he may be more easily narcotized when general 
anesthesia is used. When local anesthesia is to be employed 
preliminary drugging is too often resorted to for the purpose of 
blunting the patient’s senses so that he will not so acutely realize 
the torture to which he is apt to be subjected as the work proceeds. 
Undoubtedly the use of preliminary medication reduces the amount 
of general anesthesia necessary and its almost universal and increas¬ 
ing use would serve to attest its merit. When used as an adjunct 
to local anesthesia its merits are to some extent offset by certain 
abuses which have crept in. Liberal doses of such drugs as mor- 
phin, scopolamin and cactin, in combination, have been found to 
so dull the senses that almost any operation may be performed 
without the addition of other anesthesia. Some surgeons who have 
had difficulty in establishing good local anesthesia have found in 
this preliminary medication a panacea for all their “local” troubles, 
so to speak, and have with the aid of huge and possibly dangerous 
doses of these preliminary drugs, been able to perform painless 
operations. 

It is a mistake to class this work as “local anesthesia.” As a 
matter of fact the use of the local anesthetic in these cases plays 
only a minor part, and without the aid of the preliminary medica¬ 
tion the operation could not be done under local anesthesia provided 
by the technic employed. Such a spectacle was presented at a 
recent large clinical meeting when in the presence of several hundred 


PRELIMINARY NARCOTICS 


73 


surgeons a patient was brought in so completely “knocked out” 
that she could not respond to questions and was operated upon for 
a walnut-sized tumor of the thyroid under so-called local anesthesia. 
Even with the patient in this mental condition, the operation was 
accompanied with so much resistance on the part of the patient 
that the operator was greatly embarrassed. It was perfectly 
obvious even to a novice that this patient could not have been 
operated upon under the technic employed without the preliminary 
narcotic. 

The question as to whether or not it is desirable or safe to give 
a massive, or in fact any dose of these drugs, will be discussed 
elsewhere; but the point to be made here is that preliminary medica¬ 
tion, whether safe or harmful, if given for the purpose of obtunding 
pain which is to be experienced by the patient because the surgeon 
has failed properly to block with local anesthesia, is reprehensible 
in the extreme, and should be so considered by those who essay the 
use of the method at all. This point cannot be too clearly under¬ 
stood nor too strongly emphasized. He who cannot do an operation 
painlessly under local anesthesia alone should not hide behind the 
veil of the preliminary narcotic. As a preventive measure against 
psychic shock the preliminary hypodermic may be indicated, but 
for the prevention of pain it should have no place. 

The most logical reason for the use of preliminary medication 
is for the purpose of tiding the patient over the hours which precede 
the operation. Provided the surroundings are proper only small 
doses are required, and the solace obtained by their use is gratifying. 
In order to so narcotize a patient that a departure may be made 
from the correct local technic and the anesthesia reduced in amount, 
the dosage of the preliminary narcotic must be large and if the 
reports in the literature are correct, such dosage is not without 
danger. As the essential reason for advocating the use of local 
anesthesia is its safety, the addition of any factor which reduces 
this element is to be deprecated. Once the safety of preliminary 
medication has been established, the increased solace insured by its 
use will more than offset the somewhat disagreeable after-effects 
which may follow. Nausea and vomiting are the most important 
of these. Harris 1 has reduced these complications greatly by the 
elimination of preliminary medication. Van Hoosen, 2 on the other 
hand, who uses larger doses of scopolamin and morphin over longer 
periods than any one perhaps, reports almost an entire absence of 
disagreeable sequela*. 

1 Discussion of A. E. Hertzler’s Local Anesthesia in the Prevention of After Pain 
and Shock, Trans. Western Surg. Assn., 1914, p. 309. 

2 Scopolamin and Morphin Anesthesia, Manz, Chicago, 1915. 


74 


THE ANESTHESIA PROBLEM 


THE HOSPITAL IN RELATION TO THE ANESTHESIA 

PROBLEM. 

For all institutions it would seem that the future must demand 
the presence of one or more skilled local anesthetists who are 
competent successfully to use this form of anesthesia. In large 
institutions there should be several of these. In the smaller 
institutions throughout the country, where the services of a skilled 
general anesthetist are obtained with difficulty, the necessity for 
skilled and more extensive use of local anesthesia is of relatively 
greater importance. While the necessity for local anesthesia is 
not so great in the large institutions where general anesthesia is 
successfully administered and the margin of safety of local over 
general anesthesia is narrower, it is significant that a skilful general 
anesthetist, 1 in offering to the world the synergistic combination of 
morphin and magnesium sulphate, page 133, points out with evident 
satisfaction that by the use of this combination of drugs general 
anesthesia may be avoided and only local anesthesia used in the 
performance of major surgical operations. Why is it (if general 
anesthesia when skilfully administered is said to be entirely satis¬ 
factory by some of the most influential and experienced surgeons of 
our time) that such an authority in its administration as is Dr. 
Gwathmey exhibits such evident satisfaction in the development 
of a combination of drugs which may permit surgeons to dispense 
with its use? There must be a reason. To those who have used 
local anesthesia extensively this reason is only too apparent. 

MEDICAL TEACHING IN RELATION TO LOCAL 

ANESTHESIA. 

In this connection the author desires to call attention to the 
dearth of teaching in relation to local anesthesia in the medical 
schools of this country. The interns who come to Minneapolis 
have little or no training in the use of local anesthesia, the principles 
of which are not given them while they are attending the medical 
school. There is, perhaps, but one medical school in this country 
which has a department for the teaching of local anesthesia. It 
seems deplorable that such neglect prevails. If one were to take 
the sum total of the time spent in teaching students the technic 
of the performance of gastrectomy, removal of the hypophysis 
cerebri, aneurysmorrhaphy and other similar subjects, each of 
which is of intense interest although of little practical use to the 
recent graduate, it would be found that much time had been spent 
with but small tangible return—at least from a practical standpoint. 

1 Gwathmey, James Taylor: New York City. 


GENERAL PRACTITIONER AND LOCAL ANESTHESIA 


r 


\\ ith a view to supplying their real needs, may it not be hoped that 
the medical graduates of the future will be equipped with more than 
a slight general knowledge of this subject and that the medical 
colleges will in the future graduate men who have at least a working 
knowledge of the general principles upon which local anesthesia is 
based. 

The future will undoubtedly evidence a great change in the atti¬ 
tude toward this subject notwithstanding a statement recently made 
at a meeting of the Minnesota State Medical Association by the 
head of the Department of Surgery, that the students at our medical 
school were not taught to use local anesthesia for the reason that 
the acquisition of the technical knowledge required might inter¬ 
fere with the ability of the student to acquire the necessary knowl¬ 
edge in relation to the diagnosis and treatment of disease. While 
the position taken by this professor of surgery is unquestionably 
extreme and would be concurred in by few, it may yet be said to 
throw some light upon the woful lack of preparation on the part 
of our recent graduates in relation to the use of local anesthesia. 


THE GENERAL PRACTITIONER IN RELATION TO 
LOCAL ANESTHESIA. 

The more extended use of local anesthesia should surely act as 
a boon to the isolated practitioner of medicine, who by its use might 
frequently be saved the necessity of calling to his aid some individual 
perhaps more or less incompetent to administer general anesthesia. 
For this reason, if for no other, it would seem that graduates in 
medicine should be instructed, not only in the fundamentals of local 
anesthesia, but should have a practical working knowledge of its 
use as well. To illustrate: Suppose a country practitioner is 
called to a farmhouse to treat a fracture of the leg in an aged person. 
Under conditions as they are at present he would probably be 
compelled to call upon a brother practitioner to administer anesthe¬ 
sia while the appropriate treatment was applied. Let us consider 
for a moment some of the possibilities which such a plan offers. 
To begin with, the loss of time on the part of the physician is no 
small item. Furthermore, as few physicians are well trained in 
the administration of general anesthesia, the protection offered the 
patient under the circumstances mentioned is not great. The 
immediate and remote possibilities of trouble as a direct result of 
the anesthetic are sufficiently great to compare fairly in seriousness 
with the pathological conditions for which the patient is being 
treated. Provided the accident has happened directly after the 
patient has partaken of a large meal, the giving of a general anes¬ 
thetic would necessarily be especially hazardous. After the applica- 


76 


THE ANESTHESIA PROBLEM 


tion of splints, a plaster cast or an extension apparatus and while 
the patient is recovering from the anesthetic one of the physicians 
must remain to supervise the post-anesthetic period. 

Contrast the above picture with the treatment of a similar 
condition by the use of local anesthesia. The calling of a second 
physician would be unnecessary. The presence of food in the 
patient’s stomach would be of minor importance. The physician, 
if properly trained in the use of local anesthesia might in a few 
minutes anesthetize the patient’s limb so that reduction of the 
fracture or application of the proper splints or dressings could be 
made without great inconvenience to the patient. The probability 
of the development of pneumonia, one great danger of general 
anesthesia especially when given under these conditions and many 
other disadvantages could in this manner be eliminated. 

The reduction of dislocations, the suturing of lacerated wounds, 
the drainage of abscesses, the performance of many minor opera¬ 
tions—almost all operations if they be performed outside of a well- 
equipped hospital—demand the use of local anesthesia much more 
frequently than it is employed at present. In short, the develop¬ 
ment and training of students should be such as to equip them with 
the obvious advantages of local anesthesia where its use is so clearly 
indicated. 

THE NURSE VERSUS THE PHYSICIAN ANESTHETIST. 

The present day shows such an improvement in the methods of 
administering general anesthesia that the aforementioned features 
do not appeal with the force with which they might a decade or two 
ago, and yet what percentage of surgeons has the good fortune 
to have associated with it an anesthetist upon whom they can 
depend absolutely? How many surgeons of today would prefer to 
depend upon someone else for this important detail provided they 
could without too much outlay take care of it themselves? This 
phase of the subject is worthy of more than passing notice. 

Although the methods of administering general anesthesia have 
shown a remarkable improvement, the matter of developing anes¬ 
thetists is not a simple one. The controversy as to whether nurses 
shall be trained for this important work, or whether it shall eventu¬ 
ally be left entirely in the hands of physicians is yet to be decided. 
No matter what the ultimate outcome may be it would seem that 
considerable time must elapse before physician anesthetists will 
be available for even a fair percentage of the cases demanding 
anesthesia. To completely supply the demand for anesthetists 
with physicians would seem to be entirely out of the question. It 
is obvious that the class of surgeons who are most poorly equipped 


THE SURGEON HIS OWN ANESTHETIST 


77 


for the administration of general anesthesia are the ones who would 
derive the greatest benefit from the use of local anesthesia; and it is 
apparent that its use is being developed with considerable rapidity 
in the smaller clinics and institutions, where many important 
advances in medicine and improvements upon existing methods have 
been made. Perhaps the restricting traditions which prevent large 
institutions from adopting newly developed methods (a condition 
which does not prevail to such an extent with the individual or in 
the smaller institutions) have brought about this result. 

THE SURGEON HIS OWN ANESTHETIST. 

Regarding the employment of skilled local anesthetists there is 
some difference of opinion. Perhaps the ideal method would be to 
train certain individuals in the administration of local anesthesia. 
These individuals could prepare the patient for the surgeon so that 
he might proceed with the operation without the necessity of 
encumbering himself with details connected with the administration 
of the anesthetic. This method has been attempted in a number of 
clinics and for certain operations in which regional anesthesia only 
is necessary, even nurses have been trained so that they could 
administer anesthesia and present the patient to the surgeon for 
operation while the anesthetist proceeded to prepare the next patient. 
For such operations as the repair of inguinal hernia, thoracotomy, 
or operations where brachial anesthesia is required this method 
may prove satisfactory, but while methods of inducing local anes¬ 
thesia remain as they are at present, the greatest satisfaction will 
not be derived from this method. The difficulty of establishing 
complete and certain anesthesia and turning the patient over to the 
surgeon ready for operation places upon the local anesthetist a 
handicap, which at the present stage of our knowledge is too 
great to be overcome except in instances like those cited above. 
Again, many operations demand the use of local anesthesia in 
regions which cannot well be reached before a certain portion of the 
operation is completed. Another point, local anesthesia though 
comparatively safe should be used in as small amounts as possible 
in each instance, and it is perhaps advisable to administer the 
solution as required, feeling one’s way, as it were, and reinforcing 
the anesthesia wherever necessary as the operation proceeds. 
When depending upon an anesthetist this most desirable method is 
impracticable. As a matter of fact the possession of proper equip¬ 
ment eliminates the necessity for a separate anesthetist. With 
proper equipment the induction of anesthesia usually requires less 
than five minutes of the surgeon’s time and the labor incident 
thereto is negligible. The patient’s knowledge of the fact that the 


78 


THE ANESTHESIA PROBLEM 


surgeon is always in absolute control of the administration of the 
anesthetic makes the giving of the anesthetic by the surgeon himself 
especially desirable, as the surgeon, of all concerned, is usually the 
one in whose hands the patient would prefer to trust his destiny. 

Aside from the solace and assurance which the patient receives 
from the realization of the fact that this important detail is entirely 
under the control of his surgeon, the satisfaction accruing to the 
surgeon himself as a result of this realization cannot be over¬ 
estimated. Especially is this true with the class of surgeons who 
are unable to obtain the assistance of a skilled anesthetist. While 
the detail of administering the anesthetic is looked upon by many 
surgeons as an added burden, one must in taking stock, consider the 
counterbalancing effect offered by the opportunity he has to control 
his own anesthetic. 

THE PROGRESS OF LOCAL ANESTHESIA AND UPON 

WHAT IT DEPENDS. 

To those who are especially interested in local anesthesia and 
who believe in its efficiency, an obvious duty presents itself. They 
must, by example, as well as by precept, reduce as far as possible 
the actual discomfort which is inevitably associated with operations 
performed under local anesthesia. Furthermore, in the handling 
of patients they should make every effort to modify the present 
environment, and establish conditions which will reduce the psychic 
incompatibility which results from improper teaching, misunder¬ 
standing and carelessness. This improvement in the environment 
of patients before, during and after operation, will go far toward 
reducing the distinctly mental sufferings which they now undergo. 
By careful selection surgeons should eliminate those who for the 
present at least, are unfit for the application of local anesthesia. 
In order to popularize local anesthesia these essential details must 
be most assiduously worked out to as high a point of perfection as 
possible. The attention of surgeons must repeatedly be called to 
them and their necessity must be emphasized again and again. 
Objectionable features must be recognized and methods for over¬ 
coming them must be developed and presented to the profession. 

MIXED ANESTHESIA. 

In deciding upon a change from local anesthesia to mixed anes¬ 
thesia at some stage of an operation the surgeon’s judgment may be 
taxed to a considerable degree. He should keep in mind the best 
interests of the patient and as well the interests of future patients, 
which depend more or less indirectly upon the action taken in each 


PSYCHO-LOCAL ANESTHESIA 


79 


operation. Again, when carrying out an operation under local 
anesthesia one should consider the effect upon visiting physicians, 
nurses and friends of the patient. A question frequently to be 
decided relates to whether it would be to the best interests of the 
patient to continue the operation under local anesthesia even though 
a certain amount of distress will ensue, rather than establish general 
anesthesia. Border-line cases place a rather severe tax upon the 
surgeon’s judgment in this regard. It would seem that the safest 
rule to follow would be to allow the patient to be the judge and to 
have him understand that he may at any time request anesthesia 
by inhalation. However, there is a small percentage of individuals 
that may complain of pain or distress during some stage of an 
operation while the muscles lie flaccid and intraperitoneal pressure 
remains negative or neutral, and when the surgeon feels morally 
certain that the patient is not suffering physical pain. In these 
instances it is the surgeon’s duty to decide whether or not he will 
ignore the patient’s protest and continue the operation under local 
anesthesia, or superimpose general anesthesia. Many of these 
individuals when talking subsequently about their experience 
upon the operating table will state that everything went along 
fine and that their anesthesia was entirely satisfactory. Again, 
a certain number of individuals who have made no complaint upon 
the operating table will state after the operation that they suffered 
during its performance. Furthermore in arriving at his decision 
the surgeon should be influenced by the factor mentioned above— 
the effect the complaint will have upon prospective patients as 
reflected by his impressions and the impressions of those who are 
witnessing the operation. 

PSYCHO-LOCAL ANESTHESIA. 

This term has been applied to the method of superimposing general 
upon local anesthesia by what one might properly term camouflage. 
In other words the patient is “ bluffed” into thinking he is taking 
general anesthesia. 

The type of individuals demanding this method—that is the type 
in which the complaint made is out of proportion to the possible 
distress produced—makes the use of this method quite efficient. 
As a rule these individuals, as a class are susceptible to camouflage 
anesthesia and, are more promptly susceptible to ether than nitrous 
oxide, because the odor of ether is much more easily appreciated. 
Ether, on account of its antidotal properties, may not be considered 
especially undesirable for this class as a strong competitor of nitrous 
oxide. In numerous instances the patient has been allowed to 
inhale ether while carrying out that portion of the operation in 


80 


THE ANESTHESIA PROBLEM 


which local anesthesia could not entirely prevent pain. Certain 
of these patients have used less than 20 cc during a period of ten 
minutes and yet have felt convinced that they were under general 
anesthesia. In such cases the toxicity of ether need not be con¬ 
sidered. 

Suggestion has played a part for, as stated above, these patients 
are so constituted mentally that they fall easy subjects to suggestion 
at the hands of the psycho-anesthetist. Only those who have had 
an opportunity to observe the ease with which one may camouflage 
general anesthesia by the method detailed above can realize its 
possibilities and advantages when used under the proper indications. 

The nitrous oxide analgesia of Crile is an excellent example 
of the application of this principle. Observation of the work of this 
master will convince one of its efficiency. However, the author 
feels that a reversal of the order which Crile uses and the thorough 
establishment of local anesthesia before administering any amount 
of general anesthesia will be found of the utmost advantage in 
assisting one to dispense with the last mentioned to a large extent. 
If on the other hand, the patient’s mentality is so obtunded that 
he cannot cooperate with the surgeon the latter has no opportunity 
to check the effects of his work and to determine the actual thorough¬ 
ness of his anesthesia. 

Research in relation to local anesthesia will perhaps demand 
that the surgeon sacrifice his personal interests and that he occasion¬ 
ally violate in a slight degree the orthodox rule of allowing the 
patient the privilege of choosing general anesthesia. It is perfectly 
obvious that the technic for the performance of any operation cannot 
be perfected in any school except that of experience. However, 
after a surgeon has had considerable experience in the use of local 
anesthesia the best interests of all concerned will probably demand 
that general anesthesia be added without awaiting too definite 
indications. In this border-line class—a class that will vary some- 
what with the individual experience and mental attitude of the 
surgeon—perhaps the best procedure to follow is to substitute 
mixed anesthesia or psycho-local anesthesia (pages 78-79) without 
too great delay. 

OPERATING BY FRACTIONAL METHOD. 

One of the most important advances of modern surgery is perhaps 
a realization that surgical therapy should be applied with the least 
amount of injury to the human organism which is compatible with 
acceptable treatment. The “fractional” method of operating 
furnishes one of the means by which the patient’s resources may be 
conserved, It is well known that the great depletion following 


OPERATING BY FRACTIONAL METHOD 


81 


extensive surgical operations which are accompanied by-hemorrhage, 
trauma, exhaustion from pain, the absorption of anesthetics, 
dehydration, etc., result in delayed convalescence and in some 
instances leave an indelible impression upon the economy of the 
individual. 

In patients who require multiple operations, the plan of operating 
in successive stages, while prolonging the operative period some¬ 
what, at times, offers an excellent opportunity to circumvent the 
dire complications mentioned above. The treatment of exophthalmic 
goiter and malignant disease of the bowel are notable examples of 
conditions in which the fractional method of operating has met with 
signal success. 

Local anesthesia lends itself most ideally to the fractional regime. 
In conditions requiring an attack upon different regions of the body, 
operations may be performed under local anesthesia in successive 
stages with but a few days intervening between the different steps, 
without carrying the patient to the point of extreme exhaustion. 
The advantages of this method should be applied more frequently. 
(See Case Report No. 14,590, page 412.) 


a 


CHAPTER IV. 


EQUIPMENT AND ARMAMENTARIUM. 


NECESSITY FOR SPECIAL EQUIPMENT. 

The satisfactory use of local anesthesia requires an armamenta¬ 
rium and operating room equipment which is more or less adapted 
to its demands and which differs in many details from those required 
when general anesthesia is used. Just as the training and com¬ 
portment of the operating squad and, in fact, of the whole hospital 
personnel, may largely influence success in carrying out a surgical 
procedure, so may the details connected with the operating room 
equipment have a great deal to do with the surgeon’s ability to 
operate successfully under local anesthesia. The conscious patient 
will demand a measure of comfort and a degree of care which may 
be entirely unthought of for one under general anesthesia. The 
general equipment of the operating room should be such that the 
execution of the routine connected with the operation may be 
done deftly and with dispatch, and the arrangement of the room 
should be such as to make this possible (Fig. 9, page 94). 

From the technical standpoint the armamentarium used in 
operating when local anesthesia is used should include every appli¬ 
ance that will in any manner lessen the injury to the human organism 
and yet be compatible with a proper and efficient surgical procedure. 
While manual dexterity, training and a refined mechanical technic 
are of the utmost importance to a surgeon, the assistance which 
is to be derived from the instruments he uses is by no means negli¬ 
gible. Refined, careful, smooth and delicate technic cannot be 
expected with crude, cumbersome and ill-adapted instruments. 
A bloodvessel may be as easily clamped by a fine-pointed artery 
forceps as with a large angiotribe and with much less injury to 
the adjacent tissues. A medium-sized, properly shaped needle 
will carry a ligature through the tissues as well as will a much 
coarser one and without necessitating so much driving force. 
The use of sharp scalpels and scissors often means the difference 
between success and failure in carrying out the work. Again, 
the manner of using these instruments may greatly influence the 
result. Attention may be called to the difference in effect between 
making an incision with a scalpel by a series of gliding strokes, 
more or less parallel with the plane of the tissues and of making 
the same by forceful perpendicular pressure. 


THE OPERATING TABLE 


So 


Attention to details goes far toward lessening the handicap 
under which the surgeon who is accustomed to operating under 
the use of general anesthesia finds himself when he attempts the 
use of local anesthesia. In an effort to bring to the patient as 
great comfort as possible, the use of the following accessories has 
been adopted in the author’s operating room. The principle of 
insuring the patient against discomfort has been kept constantly 
in mind and the complaints of patients have been the basis upon 
which technical improvement has depended. The application 
of local anesthesia has been looked upon as more or less of a system 
in itself, that its successful use demands not only a revised and 
improved surgical technic, but an improvement in the general 
technic of administering to the comfort of the patient as well. 

The following suggestions relate largely to the matter of com¬ 
fort. However, details of the system have been kept constantly 
in mind and many of the adjuncts described have been designed 
or supplied because we have found them indicated when operating 
upon a conscious patient. 

This equipment, some of which is of original design but much 
of which is but a modification of the handiwork of others, is pre¬ 
sented, as are the other suggestions contained in these pages as a 
reflection of long experience regarding the demands of local anes¬ 
thesia. The following descriptions are to be looked upon as leads 
only and the author well recognizes the shortcomings of many of 
the devices described. 


THE OPERATING TABLE. 

The operating table, Fig. 1, should be equipped with accessories 
which are calculated to give the patient the greatest degree of 
comfort possible. Supports for sustaining the patient in position 
when the table is tilted should be well padded so that he will not 
find it necessary to complain of pressure, Fig. 1 -B. A simple 
device has been the utilization of a segment of the inner tube of 
an automobile tire as a padding for these supports, Fig. 1-1). 
They are equipped with valve stems and are inflated with air. 

Arm Rests.—The arms are placed in concave arm rests and may 
lie at the patient ’s sides or be extended at right angles. The 
wrists may be secured by leather straps which, while preventing 
the patient from inadvertently bringing the hands in contact 
with the aseptic field, allow some freedom of movement and at 
the same time, do not constrict the parts, Fig. 1 -C, and Fig. 84, 
page 251. The legs likewise are secured by metal bands which 
retain but do not constrict the limbs. They also permit the patient 
to have a limited amount of freedom, Fig. 1 -E. For the lithotomy 


84 


EQUIPMENT AND ARMAMENTARIUM 


position special knee holders are necessary adjuncts if the con¬ 
scious patient is to be expected to maintain this position for con¬ 
siderable periods without making complaint. It has been found 
that the leg holder illustrated in Fig. I-A meets the requirements 
almost ideally, provided the patient’s limbs are first placed in the 
proper position and the leg holder then adjusted to fit this position. 
(Fig. 141, page 346.) 



Fig. 1.—The operating table and equipment; A, universally adjustable leg holder; 
B, pneumatic supports for lateral tilting; C, adjustable arm rests; D, pneumatic 
shoulder supports; E, thigh restraints. 


Tilting.—It is desirable to use an operating table upon which 
provision is made for lateral tilting (Fig. 202, page 473) so that in 
abdominal cases the force of gravity may be utilized in bringing 
the various viscera into view. All tilting of the table should be 
accomplished by means of the worm drive so that the tilts may 
be made gradually without any jerky motion. This applies also 
to obtaining the Trendelenburg position. Provision should like¬ 
wise be made for the assumption of the reversed Trendelenburg 
position. 





































































































SYRINGES 


85 


I he operating room utensils should, as far as possible, be con¬ 
structed with the idea of eliminating unnecessary noise. Noise¬ 
less casters, fiber basins, etc., are desirable. 

SYRINGES. 

The great variety of syringes on the market attests the dis¬ 
satisfaction generally encountered with their use. If large enough 
to obviate the necessity of frequent filling, a syringe is apt to be 
more or less cumbersome. Also syringes of great capacity inter¬ 
fere more or less with the ability of the operator to gauge accurately 
the location of his needle point when injecting at some distance 
from the surface. Likewise the increased distance between the 
hand and the needle point makes it difficult to control the latter 
when introducing it. Another objection to large syringes is the 
fact that the increased friction between the plunger and the barrel 
necessitates an especial outlay of force in making the injection. 
In fact this defect is present more or less in all syringes. Not 
infrequently a slight amount of rotation of the piston is necessary 
in order to make it advance and this maneuver necessitates the 
grasping of the barrel of the syringe with one hand, a procedure 
which will almost surely interfere with the accurate control of 
the needle point. Smaller syringes or those of a size compatible 
with the proper finesse for the making of a smooth, equable infil¬ 
tration must be filled repeatedly unless one of the self-filling types 
of syringe, which will be described later, be used. Even the most 
satisfactory of these, unless perfectly made, will at times “stick,” 
necessitating the rotation of the piston before it can be advanced. 
Ordinarily the small syringe of perhaps 5 cc capacity, with rings 
for the thumb and fingers may be the most deftly manipulated. 
With a larger syringe one cannot readily appreciate or “visualize” 
what is taking place at the distal end of a long needle. Syringes 
above 10 cc capacity will be found unsatisfactory. 

In Rovsing’s Surgery of 1914 a self-filling syringe devised by 
Dr. A. Madsen of Denmark is described. Since this time several 
varieties of self-filling syringes have been devised. The most 
satisfactory of these are of glass or combined glass and metal con¬ 
struction, having a one-way valve connected with a piece of tubing 
which runs to a receptacle containing the anesthetic solution. 
This arrangement obviates the necessity for detaching the needle 
and refilling the syringe when it is empty and eliminates one of 
the disadvantages of the syringe. The use of the glass syringe 
allows one to aspirate whenever this is deemed advisable so as to 
eliminate the possibility of injecting the anesthetic solution into 
the bloodvessels. As this possibility may be practically eliminated 


86 


EQUIPMENT AND ARMAMENTARIUM 


by constantly moving the needle point while the injection is being 
made, the importance of this feature is not great. However, 
experience has shown that when using a self-filling syringe more 
or less air is apt to collect in the syringe as the plunger is with¬ 
drawn in refilling. It is a great source of satisfaction, therefore, 
to be able to note the contents of the syringe at all times, and it 
is for this reason that the glass is superior to the metal syringe. 

The Dunn Syringe, manufactured by the MacGregor Instru¬ 
ment Company, is one of the most satisfactory instruments of 
this kind to be found on the market. It has the objection common 
to all syringes that muscle tire is not eliminated, that one must 
delay while the plunger is drawn back for the refilling and that 
the injection of deep cavities is difficult or impossible because the 
hand and syringe stand between the eye of the surgeon and the 
needle point. It also shows to disadvantage when the necessity 
arises for making the injection “around the corners” in inacces¬ 
sible locations, the hand frequently being placed in an awkward 
position so that it is impossible to know the location of the needle 
point and to direct the needle as desired, while making the injection. 
The same disadvantage presents when one attempts to inject 
in deep cavities, as in the vagina, pelvis, region of the cystic 
duct, etc. 

For buccal injections the instrument devised by Fischer is per¬ 
haps the most satisfactory. Another excellent syringe for this 
work is the Mm, Kalo-Kain, manufactured by DeSanno and 
Hoskins, Inc. 

NEEDLES FOR INFILTRATION. 

Needles should be long, fine and slightly flexible. The most 
satisfactory needles have been made of steel or duro gold, ranging in 
size from 20 to 23 gauge and from 5 to 10 cm. in length. Gold- 
plated needles possess the great advantage of flexibility, dura¬ 
bility and cleanliness, but lack the strength of the steel needle. 
If needles of finer gauge are used it is difficult to prevent bending. 
The needles illustrated in Fig. 2 represent a satisfactory type. 

The author has designed special adapters and bayonet-lock 
needles, an arrangement which has proven quite satisfactory. 

The steel and gold-plated needles equipped with bayonet-lock 
and adapters to correspond, are shown in Fig. 3. The adapter, 
Fig. 3 -A, effectually prevents the needle from slipping off or becom¬ 
ing loose. One of the overt acts which not infrequently causes 
trouble, especially when doing intraperitoneal work, is the jump¬ 
ing off of the needle when the solution is allowed to flow through 
it. Many times during laparotomies an expulsive effort has been 
thus excited which resulted in the extrusion of the intestines, and 


NEEDLES FOR INFILTRATION 


87 


upon one occasion the needle was lost for a considerable length 
or time. 1 he gold-plated needles are extremely flexible, and in 
a huge percentage of work this attribute is desirable (see Fig. 4). 
oth the steel and gold-plated needles are equipped with bayonet- 



Fig. 2. —Local anesthesia needles (actual size). 



Fig. 3.—Author’s special bayonet-lock needle (flexible and constructed of steel or 
duro gold): A, adapter for same; B, stone for sharpening needles. 





















































































EQUIPMENT AND ARMAMENTARIUM 



locks with adapters to correspond (Fig. 3). The adapter, Fig. %-A, 
effectually prevents the needle from slipping off or becoming loose. 
The removal and replacement of a needle of this type requires 
but a moment of time. 



Fig. 4.—Showing flexibility of needle. 

THE PNEUMATIC INJECTOR. 

Assuming that an anesthesia by infiltration will be the method 
of choice in a fair percentage of cases and assuming further that 
rather liberal amounts of the local anesthetic solution may and 
should be introduced in order to assure satisfactory results, the 
actual means by which this infiltration is to be made assumes a 
relatively important role. A realization of this led the author to the 
development of the pneumatic injector (Fig. 5). This apparatus, 
more than any other element—and as a matter of fact more per¬ 
haps than all other items of equipment—has, by reducing to a 
minimum the labor, inconvenience, time and margin of error made 
the use of local anesthesia a delight in his clinic. 

Where direct infiltration or infiltration block is to be used this 
instrument has its ideal application; even in doing nerve blocking, 
especially in infiltration block, its use has been found to be highly 
satisfactory. The field to be covered may be traversed system¬ 
atically without the necessity of delay, without the expenditure of 




THE PNEUMATIC INJECTOR 


89 


energy, without the muscle tire which accompanies the use of the 
syringe and without the liability of “losing one’s place,” which is so 
apt to happen while syringes are being refilled. But, above all, the 



Fig. 5. —The pneumatic injector for introducing local anesthetic solutions: A, 
cylinder for anesthetic solution; B, graduated glass gauge; C, detachable posts; D, 
heavy metal base; E, pressure tank (oxygen or carbon dioxide); F, tubing; G, towel 
rack; PI, flexible metal tubing; I, cut-off (see Fig. G). 













90 


EQUIPMENT AND ARMAMENTARIUM 


most important advantage of the pneumatic injector is the elimi¬ 
nation of inadvertent motion at the point of the needle caused by 
the muscular effort required for forcing the syringe piston, often 
with the hand in an awkward position. The pneumatic injector 
cut-off may be grasped with about the same force as one would 
use in writing with a fountain pen. The “pistol grip” effect (Fig. 
6) allows one to control absolutely and to “feel” almost perfectly 
the position of the point of the needle. The position of the hands 



Fig. 6.—Valve or cut-off of pneumatic injector: A, hand piece of valve; B, ball 
and socket joint; C, needle holder; D, adapter. Note pistol-grip effect of cut-off; 
E, special bayonet-lock needle; F, record needle. 


does not change and the fluid is injected into the tissues with the 
lightest kind of pressure upon the valve. The simplicity of this 
maneuver and the possibility which it allows of “putting over” 
the early portion of the infiltration upon the apprehensive patient 
is of the greatest advantage. The apparatus is now practically 
“fool-proof,” and while at first appearance it might seem com¬ 
plicated, the only portion of it with which the surgeon comes in 
contact is the acme of simplicity. With the details of filling, 















THE PNEUMATIC INJECTOR 91 

supplying piessure and the like the surgeon need not concern him¬ 
self. 


. (^ ee (1, 7 and 8 tor detailed description of the pneumatic 

injector.) 



Fi G. 7.—“Sterile” nurse “setting up” pneumatic injector: A, unfolding tubing; 
B, introducing tubing into socket ; C, dropping yoke over lug on base of pneumatic 
injector; D, tightening set screw. Note: Tubing automatically remains in place. 















92 


EQUIPMENT AND ARMAMENTARIUM 


Detailed Description of the Pneumatic Injector.— Fig. 5, page 89, 
shows the pneumatic injector assembled and ready for use. Before 
“ setting up,” the anesthetic solution is introduced into cylinder A by 
means of a sterile funnel, after unscrewing the cylinder cap. Note: 
The adrenalin should be added to the solution before introducing 
the latter into the cylinder. The graduated gauge B is of glass 
and allows one to note at a glance the amount of solution present 



Fig. 8. —Operative mechanism of pneumatic injector: A, pressure tank; B, gas 
intake valve, by which gas is allowed to enter cylinder A, Fig. 5; C, outlet valve by 
which fluid is allowed exit through tubing F, Fig. 5; D, pressure gauge; E, safety valve. 

or being used. The cylinder A requires sterilization only once or 
twice a month and this may be best done in an autoclave. The 
tubing F, G, Id, I, is sterilized for each operation. It may be 
coiled and placed in the tray with the instruments. The posts C, 
upon which the cylinder is mounted on the base D, may be detached 
from the base of the cylinder A as may the pressure tank E after 
which cylinder A may be wrapped and autoclaved. 

The cut-off, Fig. 6, which is the only portion of the apparatus 









THE PNEUMATIC INJECTOR 


93 


with which the surgeon comes in contact, is designed to fit the 
hand of the operator with a “pistol-grip” effect. The tubing A 
is a filter, B is a ball-and-socket joint, C is a needle holder which 
retains the record needle F in place, D an adapter (see Fig. 3 -A, 
page 87) for the bayonet-lock needle, E. 

“betting up ’ Pneumatic Injector, Fig. 7. After the introduction 
of the solution into cylinder A, Fig. 5, the tubing, which may be 
sterilized with the instruments, is attached to the cylinder base 
by the sterile nurse. A shows the tubing folded, B shows the 
tubing being introduced into its socket, C shows the nurse adjusting 
the yoke of the tubing over the lug of the cylinder base. The 
tubing will now remain automatically in place while the nurse 
forces home the setscrew, as shown in D. 

The needle may now be attached (see Fig. 6) to the cut-off and 
after evacuating the air from the tubing by turning on the pressure 
and opening the cut-off, the apparatus is ready for use. 

Operative Mechanism of the Pneumatic Injector, Fig. 8. Fig. S 
shows the operative mechanism of the pneumatic injector. After 
the “setting up” process is completed, the pressure is turned on 
by opening valve on tank A. The intake valve B is then opened, 
allowing gas pressure to enter cylinder A (Fig. 5, page 89); outlet 
valve C is then opened, allowing the fluid to enter the tubing and 
cut-off. D registers the amount of pressure; from 25 to 75 pounds 
is required, depending upon a number of factors, to wit: the speed 
with which one wishes to inject the solution, the character of the 
tissues to be injected and the size of the needle, as well as the 
rapidity with which it is moved. 

E is the safety valve which “blows off” at 100 pounds. 

As soon as the patient is draped, the pneumatic injector may 
be moved to an appropriate position (see Fig. 9, page 94) and a 
towel adjusted, isolating the sterile field from the apparatus (see 
Fig. 161, page 384). 

Equipment becomes an important factor during certain stages 
of difficult operations and it is at these trying times that one needs 
every artifice in order to overcome the handicap under which he 
is placed. Most operations can be carried through with little 
difficulty except for the fact that at two or three points some 
more or less insurmountable obstacle presents itself. It is here 
that the cut-off, with the long, fine needle firmly attached, with 
automatic pressure on tap, and a perfect light, and therefore a 
perfect view of the field, enables the surgeon to place the anes¬ 
thetic at exactly the right point and with the least disturbance 
to the patient, thus effectually surmounting one of the greatest 
obstacles. 

The operating room floor plan as illustrated in Fig. 9 shows the 


94 


EQUIPMENT AND ARMAMENTARIUM 


position of the pneumatic injector before and during operation. 
The instrument after being “set up” may be moved to the desired 
position near the operating table either by the sterile nurse or by 






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the anesthetist. The sterile nurse may grasp the instrument by 
the sterile tubing in order to move the injector about. If after 
“setting up 1 a sterile towel be placed over the tubing, the cut- 














































































OPERATING ROOM LIGHTING 


95 


off and towel-rack, and the apparatus placed at the edge of the 
isolated held it is entirely out of the way. 

hig. 9 shows the arrangement of the author s own operating 
room. 

Other Uses for the Pneumatic Injector Pneumoperitoneum. —This 
apparatus lends itself to a variety of other uses, such as the making 
of irrigations and injecting formalin-glycerin solutions into joints, 
hut the most important use to which it has been put, aside from 
the one for which it was originally designed, is in producing pnewno¬ 
peritoneum. I sing an oxygen or carbon-dioxide tank for pressure, 
the cylinder which has been previously filled with sterile water 
is evacuated by pressure from the tank. We now have the 
water in the cylinder replaced by filtered gas. All that remains 
is to introduce the needle into the peritoneal cavity and to grad¬ 
ually inflate it at leisure. About 5 pounds’ pressure is used and 
the injection is made at any rate desired, depending largely upon 
the effect produced upon the patient. 

OPERATING ROOM LIGHTING. 

A good light is one of the indispensables in an operating room. 
The visualization of the tissues, especially in deep cavities, is one 
of the prime essentials for efficient and satisfactory work under 
local anesthesia. It is practically impossible to operate in deep 
cavities under natural light without being compelled to depend 
in a considerable measure upon the sense of touch, rather than 
that of sight. Most surgeons, because of a realization of this fact, 
have equipped their operating rooms with some sort of spot-light 
and one almost always sees a lamp of this kind standing in every 
operating room. However, most of these lights are poorly con¬ 
structed and are not adaptable to the service for which they are 
intended. They usually lack adjustability, are unstable and 
throw before the operator ’s eyes a glare which in many instances 
makes them a menace rather than an aid. In the carrving out of 
important work below the surface of the body we have come to 
depend almost entirely upon artificial light. A good operating 
light should give ample illumination where it is wanted without 
the production of heat so intense that the surgeon anti his assistants 
are uncomfortable when working under it even for any length of 
time. In order to obtain sufficient illumination when working in 
deep cavities, so that one may depend upon the sense of sight 
rather than the sense of touch, it is necessary to eliminate the 
shadows produced by the heads of the operator and his assistants. 
Furthermore, on account of the fact that the plane of operation 
is changed so frequently, the direction of the light should be under 


96 


EQUIPMENT AND ARMAMENTARIUM 


control. For instance, it may he necessary to direct the light 
into the pelvis, beneath the lower surface of the liver to the region 
of the common duct, beneath the abdominal wall to the region 
of the spleen or ureter, into the oral cavity, into the vagina or 
rectum, into the thorax, etc. In order that these various cavities 
may be illuminated, no matter in what plane the wall surrounding 
the opening leading to them lies, it is essential that the light comes 
from a variety of sources and that the plane in which the lights 



Fig. 10.—Author’s “elephant-trunk” operating room lamp. (Portable, universally 

adjustable and self-cooling.) 


are clustered be adjustable. We have found that the light of the 
Bartlett type gives more satisfaction than does a lamp in which 
all the light comes from one source. In order, however, to obtain 
the maximum benefit from such a light, its plane must maintain 
a constant relation to the plane of the operative field and further¬ 
more the distance between the light and the operative field must 
not vary to any great extent, and should be under control. Lights, 
therefore, of the Bartlett type which are permanently fixed to the 














THE AUTOMATIC WIRE-SPRING RETRACTOR 


97 


operating room ceiling, even though their planes are adjustable, 
have proven disappointing on this account. They necessitate 
frequent excursions of the operating table in order to bring the 
field of operation into line with the area of the most intense illumi¬ 
nation and this distance from the operating field cannot be regulated. 
As it is necessary when working under the local method to dissect 
carefully with sharp instruments and with but slight traction 
and as deep structures cannot be readily dislocated and brought 
to the surface while working under this form of anesthesia, an 
adjustable light which eliminates shadows and illuminates all deep 
cavities is desirable. Fig. 10 illustrates a lamp which effectually 
fulfils these requirements. 

The Elephant Trunk Lamp.—For the reasons above cited the 
elephant trunk lamp, Fig. 10, was designed and it proved to be 
satisfactory in every detail except one; that is, that in order to 
obtain the maximum intensity of light, a rather uncomfortable 
amount of heat was produced by the radiation from the bulbs. 
Therefore, a ventilation fan was established at the proximal end 
of the horizontal tube which carries the cluster of lights. This 
fan, which is operated by a noiseless motor, carries the heated air 
The horizontal tubing, as well as the lamp shades, are 


a wav 


constructed with air-tight joints and the accumulated heat from 
the lamp is thus effectually removed. This lamp possesses the 
attributes required at some stage of almost every operation. The 
lamp is equipped with a heavy base, which gives stability, mounted 
upon noiseless casters and stands sufficiently far from the operat¬ 
ing table so that the surgeon and his assistants may walk between 
it and the operating table without danger of a break in asepsis. 
The plane of the cluster of lights may be changed at will by means 
of a tiller wheel, and the distance of the cluster from the operative 
field may be adjusted by means of a crank and worm drive. For 
ligations or emergency operations in the patient ’s room this light 
is most satisfactory, as a nurse may transport it from one room 
to another, at will. 


THE AUTOMATIC WIRE-SPRING RETRACTOR. 

The utilization of the time and energy of an assistant and the 
inability of an individual to constantly retain a retractor in position 
without change for any considerable period of time has led to the 
development of various types of self-retaining instruments. Most 
of these are of the rigid type, possessing great strength and are 
potentially destructive in character. When introduced into a 
wound they are usually forcibly expanded and as their construction 
offers the surgeon considerable leverage, the result is that the 
7 


98 


EQUIPMENT AND ARMAMENTARIUM 


desired exposure is obtained and continued too frequently with 
damage to the retracted tissues. An appreciation of the fact 
that perfect exposure and instrument contact are desirable makes 
good retraction practically a necessity. The use of local anesthesia 
makes special demands in this regard. 



Fig. 11.—Author’s automatic wire-spring retractors. Nos. 1, 2, and 3, for skin and 
muscle retraction, and 4, for abdominal, bladder and vaginal surgery. 


It was in an effort to obtain the advantages of the self-retaining 
retractor and at the same time to avoid some of the shortcomings 
mentioned, that led to the development of the Automatic Wire¬ 
spring Retractor which practically fulfils the demand for retraction 
in most of the surgical fields. (Figs. 11, 12.) 






99 


TIIE AUTOMATIC WIRE-SPRING RETRACTOR 


1 lie Automatic \\ ire-spring Retractor presents many desirable 
attributes. Rigidity is eliminated. The application of this 
instrument results in a gradual, symmetrical, constant, automatic 
spreading of the wound, which is exceedingly desirable when using 
any form of anesthesia, but especially so under the use of local 



Fig. 12.—Various types of abdominal retractors. (Nos. 5, 6 and 7.) 


anesthesia. It produces a gradual, elastic stretching of the muscles 
without traumatization of the tissues and without the excitation 
of reflex action. The use of this form of retraction has demonstrated 
the fact that incisions are found to increase gradually in size for 
several minutes following the introduction of the retractor and 


> > > 





























1(30 


EQUIPMENT AND ARMAMENTARIUM 


this without producing reflex contraction, or what might be called 
a combative action on the part of the muscles. The avoidance 
of this combative action is especially desirable in all work under 
local anesthesia since the occurrence of muscle spasm is usually 
accompanied by discomfort on the part of the patient. 

The Automatic Wire-spring Retractor has its most important 
application in surgery of the abdomen, where a combative action 
on the part of the muscles is not only discomforting to the patient, 
but is likely to result in an expulsive effort, with the extrusion of 
more or less of the contents of the abdominal cavity. 



Fig. 13.—Retractor with coil spring for grasping ligatures. 


The substitution for retraction by an assistant, which is always 
more or less “jerky,” by the constant steady pull of the auto¬ 
matic retractor and the avoidance of trauma, are the special points 
of excellence of this instrument. 

In case the enlargement of a wound becomes necessary the 
automatic spring retractor will immediately take up the slack, 
thus requiring no further readjustment. 

This instrument is available in various sizes and strengths. 
Thus it is applicable to almost every incision in which retraction 
is required. Furthermore, the small amount of space which it 
requires makes it possible to superimpose one upon another with¬ 
out in any manner interfering with or encroaching upon the opera¬ 
tive field. Thus in the hernia operation one pair of retractors 



( 


(, •*. 







THE AUTOMATIC LIFTER 


101 


may be used to separate the skin and fat layers, a second the layers 
of the external oblique and if necessary another set may be intro¬ 
duced more deeply. When closing the incision the retractors 
may be removed in an order inverse to that in which they were 
introduced and thus at all times present to the surgeon a perfect 
view of the various tissues. Fig. 13 shows a retractor with a 
coil spring attachment which may be utilized for retaining the 
loose ends of ligatures when occasion requires. This obviates 
the necessity of picking these ends up with forceps. In elevating 
the abdominal wall (vertical retraction) the strong, smooth retractor 
Fig. 14 is used. (Fig. 170, page 396.) 



Fig. 14.—Retractor used for elevating abdominal wall. 


THE AUTOMATIC LIFTER (Fig. 15). 

A constant source of discomfort and in many instances the 
cause of a great deal of pain is the transportation of the injured or 
very ill patient to the operating room and back to bed. Crile 
overcomes the pain in desperate cases by the administration of a 
light gas analgesia in bed and this analgesia is continued until the 
patient is once more returned to bed after the operation is com¬ 
pleted. The indications may be met to some degree by the use 
of the utmost care in handling patients but even where every pre¬ 
caution is used the making of the four shifts which are usually 
necessary is always a source of discomfort to the patient. True, 
the return trip from the operating room may be made with the 
patient unconscious, provided general anesthesia is used, and yet 
how frequently a patient is seen who has just undergone a severe 
operation and who is in fair condition, go into collapse during the 
trip back to his room. It is at this critical stage that rough handling 
is most apt to be disastrous, even though the patient is unconscious. 
It only serves to emphasize the fact that trauma, so inimical to 
the best interests of our patients, whether they are awake or asleep, 
should be reduced to the minimum in every case. 

In relation to the use of local anesthesia, the avoidance of dis¬ 
comfort during the voyage to and from the operating room assumes 
an especially important role. It is essential that pain and dis¬ 
comfort be avoided, provided this can be done, and by the use of 














102 


EQUIPMENT AND ARMAMENTARIUM 


the Automatic Lifter, Fig. 15, this has been shown to be entirely 
possible. It makes no difference what the nature of the illness 
may be, by means of this apparatus any patient may be trans¬ 
ported from the bed to the operating table, or vice versa, with 
almost no discomfort whatever. The elimination of the orthodox 
method of lifting patients has been a source of the greatest satis¬ 
faction. In the use of the narco-local method the apparatus is 
invaluable, as the patient can be transferred without realizing that 
he is being moved, even under the influence of very light doses. 



Fig. 15.—Author’s automatic lifter. A, B and C, leather stretcher pads; D and E, 
supplementary straps; F, lifting mechanism; G, vertical post; H, crank. Insert— 
Patient elevated and wrapped in blanket. 


Fracture cases, those with septic joints, or those with acute 
abdominal conditions should be transported with the minimum 
amount of trauma not only because such treatment insures increased 
comfort, but in order that actual local injury may be avoided. In 
localized abdominal abscesses the possibility of intraperitoneal 
rupture is always present and the author has seen a number of 
patients in which this accident has happened. The adjustment 





























































































THE AUTOMATIC LIFTER 


103 


of a patient to the desired position upon the operating table is 
also often fraught with difficulty, especially when dealing with 
the desperately sick. With this apparatus a nurse, unaided, may 
transport a patient of any weight without disturbing him in the 
least. The apparatus is especially useful in transporting the 
unconscious or helpless patient. The illustrations demonstrate 
more clearly than the text could possibly do some of the various 
uses to which this apparatus is adapted. Fracture eases, and in 
fact, all cases may be transferred without change of the relative 
positions of the limbs or trunk. 

Description of the Automatic Lifter.—The Automatic Lifter, 
Fig. 15, consists of a frame constructed of angle iron and mounted 
upon ordinary hospital stretcher wheels. A, B, and C represent 
the leather supports, and combined they form the hammock in 
which the patient lies while being transported. The hammock 
being divided into three parts, A, B and C, may be easily placed 
beneath the patient. The extremely ill, as those with bad fractures, 
may be lifted upon the leather straps, D and E. The lifting 
mechanism, F, consists of a parallelogram, which is elevated and 
lowered by the means of a worm drive. In changing its position 
this parallelogram follows the geometric law that the opposite 
sides of a parallelogram always remain parallel to each other. 
This makes it possible to maintain the post G, in a vertical position 
parallel with the frame of the elevator when the patient is raised 
and lowered by the means of the worm drive and crank, H. As 
soon as the patient is elevated from the bed a blanket may be 
wrapped about him as shown in the insert. In case a patient is 
extremely ill one may use stiff leather straps with which to raise 
him, until the soft leather pads are placed. One can always find 
space through which to push the leather straps. In case a plaster 
cast is to be applied one may use straps exclusively beneath the 
affected area and withdraw them after the application of the cast. 
Obviously if all straps are brought into contact with the patient’s 
body and the tension upon all of them is made equal the patient 
must leave the bed with no change in the relative position of the 
parts. 

Ever present danger of disseminating septic material about the 
abdominal cavity, before, during, and after operation has been 
referred to. The automatic lifter becomes at once the surgeon’s 
ally in the effort to prevent this spread of infectious material. 
It makes it possible for the surgeon to receive the patient upon 
the operating table in the condition in which he was seen before he 
left the bed; and after an operation, which should be accomplished 
with the least possible trauma and soiling, it insures the patient s 


104 EQUIPMENT AND ARMAMENTARIUM 

return to bed in the same condition in which he was when he left 
the operating table. Practically all of the author’s patients are 
transferred to bed following an operation by the means of this 
device and all who might be caused pain during the transfer to 
the operating room are likewise conveyed upon this apparatus. 
As an adjunct to local anesthesia and the general method of hand¬ 
ling the sick, it is most valuable. 

THE GOITER CLAMP (Fig. 16). 

In thyroid surgery, even in the absence of pain, the frequent 
grasping and dropping of a mobilized gland is a constant source 



Fig. 16.—Author’s goiter clamp. 


of embarrassment to the surgeon and patient alike and while the 
surgeon may become accustomed to grasping and regrasping a 
slippery gland when working under general anesthesia, this dis¬ 
turbing element will frequently cause complaint on the part of 
the patient and may often result in embarrassment of respiration. 

Small tumors may perhaps be most easily grasped by tow r el 
pins. However, large tumors or those that are difficult to handle 
may be easily controlled by the use of the goiter-holding forceps. 
Fig. 16. 







THE PROSTATIC RETRACTOR 


105 


As soon as the gland is mobilized it is grasped by the parallel 
rings of this forceps, the handle of which is turned over to an 
assistant. It then becomes the assistant’s duty to prevent the 
patient from complaining, by holding the gland at all times in 
proper relation to the trachea to which it is attached. Incidentally, 
the clamp prevents bleeding from the gland itself and reduces to 
a large degree the number of artery forceps necessary, as it is 
found they need only be applied to the proximal limb of each vessel 
before it is divided. Its use may also prevent the squeezing “goiter 
juice” from the gland in toxic cases, a factor which is thought by 



some authorities to be responsible for some of the sequelae of opera¬ 
tions of this type. Fig. 78, page 241, shows the goiter clamp in use. 

In goiter and abdominal work, the delicate forceps devised by 
Bainbridge (Fig. 17), are also found to be of assistance when 
dividing the muscles. While effectually preventing hemorrhage 
they cause a minimum amount of trauma. In our stomach and 
intestinal work these instruments have been found very satisfactory, 
and have been used largely to replace the heavier clamps, except 
where crushing is desirable. 










106 


EQUIPMENT AND ARMAMENTARIUM 


THE PROSTATIC RETRACTOR. 

The prostatic retractor was devised for transfixing and elevating 
the prostate during the operation of suprapubic prostatectomy. 
Fig. IS, also Figs. 132 and 133, pages 333 and 334. 



Fig. 18.—Author’s prostatic retractor. Closed and open. 


THE VISCERA RETAINER. 

One of the most distressing conditions with which one meets 
is the extrusion of the abdominal viscera while closure of the abdo¬ 
men is being made. While operations may, as a rule, be com¬ 
pleted with a perfect negative pressure one may find, especially 
in acute inflammatory conditions or in the case of umbilical hernia, 



Fig. 19.—Author’s viscera retainer: B, reversed rubber glove applied. 
















THE VISCERA RETAINER 


107 


that the peritoneal cavity does not present sufficient space, so to 
speak, to accommodate all of the abdominal viscera. For the pur¬ 
pose of meeting this contingency the viscera retainer (Figs. 19 
and 20) was devised. Its use effectually eliminates the trauma 
to which the viscera are subjected when gauze is used and its easy 


Fig. 20.—Author’s viscera retainer in use. 



removal substitutes another of the shortcomings of the gauze 
pad, which is always difficult to remove and is apt to bring intestine 
and omentum away with it. The viscera retainer is placed with 
the blades closed within a reversed rubber glove, the fingers o 
which are allowed to remain unturned. A dry glove may be used 
or the glove may be moistened before introducing the instrument. 







108 


EQUIPMENT AND ARMAMENTARIUM 


The author prefers to use the dry glove for the reason that the 
intestines and omentum adhere to the dry rubber for a short period 



Fig. 21. —Prostatic “hook.” (Curved elevator.) 


of time and, therefore, do not creep around and into the field. 
The deeper layers of the wound may be brought into apposition 
until the wound is reduced to about 5 to 7 cm. in length, Figs. 



19 and 20. The blades of the retainer may then be closed and the 
instrument withdrawn. The glove may be left in situ, to be with¬ 
drawn later, or may be removed with the retainer if desired. 



Fig. 23.—Moynihan cystic duct clamp. 


Fig. 21 represents a curved elevator, designed for bone work 
but which has been utilized by the author in the enucleation of the 
prostate. 


























THE VISCERA RETAINER 


109 



Fig, 25.—Fenestrated rectal dilator. 









































110 


EQUIPMENT AND ARMAMENTARIUM 


Fig. 22 represents bone shears of the heavier type, employed in the 
division of ribs, the bunion operation, laminectomy, and such opera¬ 
tions. Its great strength allows one to divide bones with a minimum 
of traction and manipulation. 



Fig. 26.—Author’s rubber-tipped intestinal forceps. 


Fig. 23. This instrument, called the Moynihan clamp, is designed 
for the clamping of the cystic duct and on account of its length is 
especially desirable when using local anesthesia. 

Fig. 24.—Varieties of the Pratt rectal dilator (see page 109). 

Fig. 25. Fenestrated rectal dilator (see page 109). 

Fig. 26. Rubber tipped intestinal forceps. 








CHAPTER V. 


GENERAL TECHNIC. 

THE PRINCIPLES OF THE APPLICATION OF LOCAL 
ANESTHESIA TO SURGERY. 

The technology of the establishment of anesthesia by the local 
method is graphically depicted in the literature upon this subject. 
C oncretely, it comprehends the injection of an anesthetic solution 
into or in the immediate vicinity of the sensory nerve supply of the 
part which is to be attacked surgically. 

The principles of the method of producing anesthesia or analgesia 
by bringing solutions of certain drugs into contact with the sensory 
nerves are fairly well understood. They are the same regardless 
of the extent of the surgical procedure. The removal of a small 
sebaceous cyst under local anesthesia differs only in degree and not 
in principle from the removal of a lipoma weighing many pounds. 

A Definition of the Terms Employed.—Various descriptive terms 
have been developed in order to designate the different methods 
which are used in inducing local anesthesia. 

Infiltration Anesthesia. —Infiltration anesthesia, which was first 
introduced by Schleich, who, with Reclus, developed this method 
extensively, comprehends bringing the anesthetic solution into 
contact with the ultimate arborizations of the sensory nerves 
(see pages 137 to 149). 

Regional or Conduction Anesthesia. —Interrupting the nerves at 
any point along their course proximal to their peripheral endings 
has been termed “regional” or “conduction” anesthesia (see page 
137). 

Regional or conduction anesthesia may be brought about by 
bringing the solution into contact with a nerve, a method which 
has been termed perineural anesthesia, 

or by injecting the solution directly into a nerve, intraneural 
anesthesia, 

or by injecting the solution into a vein, venous anesthesia (see 
page 112), 

an artery, arterial anesthesia (see page 114), 

or by injecting into the spinal canal, intraspinal anesthesia. 

Various other terms have been suggested to describe amplifica¬ 
tions or modifications of the regional methods; for instance, the 


112 


GENERAL TECHNIC 


circumferential infiltration of Hackenbruch, which is merely a peri¬ 
neural or intraneural blocking of the nerves supplying a given 
area (Fig. 30, page 129). 

Infiltration Block.—Regional and conduction anesthesia in the 
refined sense comprehend the accurate deposition of a small 
amount of solution exactly in the region of or within the nerve 
sheath. The attainment of such accuracy is somewhat difficult 
and a more or less general infiltration in the approximate region in 
which the nerve is known to lie is often substituted. This method 
we have designated infiltration block (see Figs. 42, 43, 44, page 187). 

VENOUS ANESTHESIA. 

Venous anesthesia was devised by Bier in 1908. Braun considers 
it a very effective method and the following is his description of the 
technic (see Braun, page 163): 

“The entire extremity is sterilized, elevated and made bloodless 
by a rubber band carried from the toes or fingers to above the place 
where the injection is to be made. Immediately above this bandage 
a second rubber band is passed about the extremity. The first 
bandage is then removed for a distance of about a hand-breadth 
and not more than three hand-breadths from the upper bandage. 
At this point the second compression bandage is placed. For 
peripheral portions of a limb direct anesthesia can be carried out 
with one constricting band which, however, should not be placed 
higher than the middle of the forearm or leg. Operations on 
infected tissues should only be carried out by indirect vein anesthesia. 
For this purpose a compression band is placed above the infected 
area, and at this point the bandage for producing anemia begins. 
The second compression bandage is then placed above the latter. 
Just under the upper constricting band one of the larger sub¬ 
cutaneous veins, such as the cephalic, basilic, median or great 
saphenous, is freely exposed under infiltration anesthesia. In 
order to render the location of the veins certain it is advisable, 
before applying the bandage for producing the anemia, to mark the 
course and position of the vein, or expose the vein before applying 
the bandage. The author advises the latter method, so that the 
patient will not be allowed to suffer from the compression bandage 
remaining unnecessarilv long upon the limb. 

“ The syringe recommended by Bier is of 100 cc capacity, 1 con¬ 
nected with a cannula by means of a thick-walled rubber tube. The 
cannula is provided with a cock so that it may be closed, and has 
two furrows at its end for the purpose of tying it into the vein. 

1 The pneumatic injector, Fig. 5, p. 89, is excellent for this purpose. 


VENOUS ANESTHESIA 


113 


1 lie cannula is tied into the vein in the same manner as for salt 
infusions, except that it is tied into the peripheral and not the 
cential end of the vein. Injections are made under even pressure, 
or, as occasionally happens, very strong pressure, until the vein 
\ ah es are overcome, 0.5 per cent novocain solution without supra- 
renin; 40 to 50 cc for the upper extremity and 70 to 200 cc for the 
lower extremity, depending upon the thickness of the limb. If 
during the injection some of the smaller branches are seen to spurt 
they must be immediately closed with hemostatic forceps. After 
completing the injection the cannula is closed by means of the cock 
and the vein is ligated and cut, the small wound being closed by 
suture. ( omplete anesthesia will occur throughout the entire 
transverse section of the limb in about five minutes; indirect 
anesthesia as well as complete motor paralysis in the peripheral 
part ot the limb follows in about five to fifteen minutes. At this 
time the peripheral constricting band can be removed in case it 
interferes with the performance of the operation. 

“ The anesthesia lasts as long as the upper constricting band 
is kept in place. As soon as it is removed, sensation returns in a 
few minutes. According to the observation of Bier, the addition 
of suprarenin to the novocain solution does not prolong vein anes¬ 
thesia very materially, but it frequently prevents an even distribu¬ 
tion of the injected solution throughout the transverse area, for 
which reason it should not be used. 

“Vein anesthesia should be used in suitable cases and is without 
danger. Poisoning from novocain need not be feared following 
its use. The cases most suitable for vein anesthesia are resection 
of joints and amputations from about the middle of the thigh or 
upper arm downward. This method should not be used when 
operating for diabetic gangrene (Bier). It is also a question whether 
this method should be used in septic infections, as it is possible 
to open a vein which is infected, even if some distance from the 
diseased area. 

“The upper constricting bandage causes severe pain after a short 
time. Perthes has devised a compressor which has relieved this 
somewhat. Momburg advises after anesthesia has set in that a 
second compression bandage be placed in the area of direct anesthesia 
and the bandage causing the pain removed. The rapid return of 
sensation following the removal of the bandage is very inconvenient 
in amputations, as the operation must have been previously com¬ 
pleted, hemostasis being rendered very difficult. The literature 
on the subject of vein anesthesia is very scanty. Schlessinger 
believes it is possible to dispense with the artificial anemia by the 
injection of larger quantities of novocain solution. He punctures 
a congested vein with a thin trocar, places the constricting bandage, 

8 


114 


GENERAL TECHNIC 


and injects. This method does not explain,, however, the manner 
in which the pressure of the vein valves is overcome. Jerusalem, 
Mantelli, Hitzrot, Goldberg, and Petrow report successful results 
with this method. Von Eiselberg states in the discussion of the 
report of Jerusalem that he only used the vein anesthesia when other 
anesthetic methods were contraindicated. The author holds this 
ingenious method of Bier to be a valuable addition to our anesthetic 
methods in performing aseptic operations upon the extremities 
when the usual local anesthetic methods are not possible. Bier 
himself limits this method of anesthesia to those cases in which 
local anesthesia is not possible.” 

ARTERIAL ANESTHESIA. 

Quoting further from Braun (page 166): “Goyanes, a Spanish 
surgeon, reported in 1909 the practical application of arterial anes¬ 
thesia, and stated in 1910 that he had performed amputations and 
resections in 23 cases with its use. In 20 of these cases complete 
anesthesia was obtained. Oppel performed many operations upon 
the hand and foot, using the radial, dorsalis pedis, femoralis and 
brachialis as arteries of injection. The leg is made anemic and 
ligated; below the constricting ligature the artery is exposed and the 
anesthetic injected by means of a fine needle. Goyanes used for 
this purpose 50 to 200 cc of a 0.5 per cent novoeain-suprarenin 
solution. Smaller doses were found insufficient by Oppel. Goyanes 
recommended this method particularly for the upper extremity, 
using lumbar anesthesia for the lower extremity. 

“Hotz has recently controlled the experiments made for arterial 
anesthesia. He recommends that the artery be exposed under 
local anesthesia and the leg made anemic just as in vein anesthesia 
ligated above. A fine needle is then passed obliquely into the 
artery and a 0.5 to 1 per cent novocain solution with suprarenin 
injected. For the brachial artery 20 to 25 cc are necessary. For 
the femoral artery 40 cc of a 0.5 per cent novoeain-suprarenin 
solution should be used. One or two minutes after the injection 
complete anesthesia occurs in the area supplied by the artery. 
Following the use of stronger novocain solutions (3 per cent) severe 
pain occurs. After relieving the constricting bandage sensation 
returns immediately. In this manner ten operations were per¬ 
formed on the hand, forearm, foot and leg. In three lean patients it 
was found possible to inject the novocain solution into the femoral 
and brachial arteries without exposing them. In these cases the 
injection was rapidly made and the leg immediately ligated. 

“Injurious effects were never observed. This method, according 
to Hotz, does not enter into serious competition with inhalation or 


SACRAL ANESTHESIA 


115 


local anesthesia. It is of value in tuberculous patients, in the aged 
w \th bronchitis and heart lesions, and other cases which are not 
suitable for general anesthesia. 

1 hat the extremity must be ligated above the anesthetized 
aiea and that sensation returns very quickly after releasing the 
constricting. bandage is a disadvantage that exists with arterial 
anesthesia just as with vein anesthesia. Arterial anesthesia 
possesses the added disadvantage over vein anesthesia in that it is 
much more difficult to find the artery than a superficial skin vein. 
This method should scarcely be given further consideration in 
anesthesia of the upper extremity, as plexus anesthesia is a much 
easier procedure. 

The above-named authorities, as well as Girgolaw, claim that 
the intra-arterial introduction of an anesthetic is less toxic than that 
introduced intravenously, but this is of no practical importance, 
as the ligating of an extremity according to the method of Bier 
renders such danger impossible. Experiments which the writer 
made on animals in 1900 also contradict any such theory. The 
toxicity of these methods depend upon the manner of injection. 
If cocain is injected into a previously ligated or clamped artery its 
toxic action is naturally much less than if this poison were injected 
into a vein with an uninterrupted circulation. If, however, the 
cocain is injected into the circulation of a vein previously ligated or 
clamped, as is done in Bier’s vein anesthesia, the toxic action will 
naturally be much less than if injected directly into an unobstructed 
artery. Therefore, we can say with equal right that cocain injected 
intravenously is less toxic than when injected intra-arterially.” 


SACRAL ANESTHESIA. 

Cathelin was the first to inject anesthetic solutions into the 
epidural space by the route of the sacral foramen. During recent 
years this method of obtaining anesthesia of the nerves arising from 
the sacral canal has been employed rather extensively. The technic 
of its establishment is comparatively simple, and although there is 
some margin of error, the method has decided advantages and is 
indeed the method of choice for the treatment of a variety of 
conditions. There is no unanimity of opinion regarding the 
amount or strength of solutions required. On the one hand it is 
recommended that an amount not to exceed 30 cc of 0.5 of 1 per 
cent novocain-adrenalin be used, while again recommendations for 
the use of 100 to 120 cc of 1 per cent solution have been made. 
There is also considerable variation in the height to which anesthesia 
may be obtained. Also the intensity varies to a considerable degree. 

Occasionally an anesthesia up to the third or fourth thoracic 


116 


GENERAL TECHNIC 


nerves has been observed. Ninety to 120 cc of a 0.5 or 1 per cent 
novocain solution has given us the best results. 

Steel needles, sizes 17 to 21, from which the temper has been 
removed by annealing, are used (Fig. 27, A and B). One type is 
equipped with blunt obturators which facilitate passage along the 
sacral canal and safeguard them from entering the veins. The 
patient is placed in the prone position (see Fig. 28). The skin and 
subcutaneous tissues over the sacrococcygeal junction are anes- 



Fig. 27.—Author’s needles for sacral anesthesia. A, sharp; B, blunt with obturator. 


thetized and a small puncture of the skin made with a tenotome 
in case the blunt needles are used. When sharp needles are 
used it is not necessary to make the preliminary puncture. After 
the introduction of the needle through the sacrococcygeal mem¬ 
brane and into the sacral canal the fluid is introduced slowly, being 
careful to avoid complaint of pain along the course of the nerves. 
In the experience of the author slight toxic symptoms are not 
uncommon in this form of anesthesia, and in very fat women the 
sacral hiatus is sometimes difficult to locate- Provided this form 











SACRAL ANESTHESIA 


117 


of anesthesia is proven safe it would seem probable that it will 
become the method of choice for pelvic, rectal and bladder work. 

he toxic s> mptoms consist of pallor, accelerated pulse and nervous¬ 
ness, but they have seldom been alarming. One case of infection 

followed the introduction of the sacral needle which necessitated 
drainage. 

The Case report is included because it is the only one in which 
an infection following sacral injection has occurred in the author’s 
clinic. Since the dura is not punctured, this complication need be 
treated onl\ like anv infected wound by establishing liberal drainage. 



Mrs. E. K. R. Female, aged thirty-eight years, married, entered 
the hospital March 22, 1921. 

History .—The patient complains of severe stabbing pains in the 
left loin, which have a sudden onset, last but a few seconds and are 
followed by an aching sensation for several minutes, preventing a 
deep inspiration. She has backaches frequently, as well as soreness 
in bladder region, with urgency a few minutes after emptying the 
urinary bladder. 

Physical examination and fluoroscopy negative, but on her first 
visit the urine showed both pus and red blood cells. 

Diagnosis .—Suspected kidney lesion (not proven). 

Operation. —Cystoscopy; ureteral catheterization; pyelograms. 

Anesthesia .—Sacral injection, 90 cc 0.7 per cent novocain- 
adrenalin solution being used. 

The cystoscopic findings were negative, but eight days after the 
examination the patient began having pain in the region of the 



























































118 


GENERAL TECHNIC 


sacrum and referred down both legs with slight redness at site of 
the sacral injection. Five days later a seropurulent discharge 
from the puncture wound presented and a week later liberal drainage 
under circuminfiltration was established, after which healing was 
uneventful. 

Note .—Since the above complication has occurred rigid attention 
has been paid to the care of the site of injection, first, sealing the 
puncture wound with rubber cement, and second, aiming to prevent 
a pool of water from accumulating and bathing the sacrum. 

The greatest satisfaction in attempting to locate the sacral hiatus 
has been found by using a long, fine needle for the purpose of making 
the initial wheal as well as the infiltration down to the bone. This 
infiltration is carried out by a series of advances and recessions with 
the needle which at each advance is made to take a different angle. 
As the needle approaches the sacrum its advance will be interrupted 
in case the point strikes this bone. If, however, the needle point 
should enter the sacral hiatus this resistance will not be felt and one 
may be certain that the needle point has entered the canal. The 
needle is then detached from the syringe or cut-off and used as a 
guide for the introduction of the regular needle which is used for 
making the sacral injection. Since using this method the sacral 
canal has invariably been located. 

James E. Thompson, 1 in a most interesting article entitled “An 
Anatomical and Experimental Study of Sacral Anesthesia” states: 
“Sacral anesthesia has become so firmly established in the surgical 
clinic of the John Sealy Hospital, Galveston, Texas, as one of the 
safest and most valuable means of producing local anesthesia in the 
regions supplied by the sacral nerves that it has passed completely 
beyond the experimental stage. It is used as a routine procedure 
in all operations on the anal canal and lower rectum, in perineal 
operations, in external urethrotomies and in operations on the body 
of the penis. Also, when combined with local infiltration of the 
abdominal walls in cystotomies and suprapubic prostatectomies.” 

He follows closely Harris of Chicago and injects but 30 cc of the 
solution into the sacral canal. To this amount of solution he adds 
10 drops of a 50 per cent solution of sodium chloride. He states 
that he repeats the injection without hesitation in case he fails to 
obtain anesthesia. The second injection has always produced 
perfect anesthesia. He has never seen toxic symptoms. In 
appended charts, made by Prof. William Keiller, he shows the area 
of distribution and intensity of anesthesia and finds that they 
present considerable variation, in some instances anesthesia as high 
as the tenth thoracic appearing. In making experimental injec- 


1 Ann. Surg., 66, 718-722. 


PARASACRAL ANESTHESIA 


119 


tions upon the cadaver he found that the solution was never injected 
within the dura mater. In every case injected the colored solu¬ 
tion used was found above the third thoracic. It was also found 
that while the injection was being made the solution flowed from 
both external iliac veins. Thompson suggests “that the needle 
had probably punctured a large vertebral vein and that the fluid 
was being forced into the systematic venous system. The possi¬ 
bility of repeating this in the living subject is suggested.” 

Thompson collected a variety of sacra, examining 33 specimens 
in all, and he found considerable variation in their shape as well as 
in the contour of the sacral canal. Harris and others have called 
attention to the same thing. This variation in shape and contour 
furnishes one of the shortcomings of sacral anesthesia, inasmuch as 
one may on this account have difficulty in entering the canal with 
the needle. 


PARASACRAL ANESTHESIA (Fig. 28). 

The sacral nerves may also be reached from in front; that is, by 
passing the needle between the rectum and the sacrum. This is 
known as “parasacral anesthesia.” (Fig. 28, page 117.) Braun 
states that the method of Franke and Posner, who attempted to 
locate the pelvic nerves by making injections in the region of 
the sympathetic ganglion of the uterine cervix, using a needle 
15 cm. long, is less simple than it is to block the sacral nerves at 
their point of emergence from the sacral foramen. He says (Braun, 
page 319): 4 ‘In this way the pelvic nerves, the entire pudendal plexus 
and the posterior cutaneous femoral nerve are interrupted and a com¬ 
plete anesthesia of the pelvic organs and lower part of the pelvic peri¬ 
toneum is obtained. This procedure we will call parasacral conduc¬ 
tion anesthesia, deriving the idea from the paravertebral anesthesia 
of Sellheim and Lawen, in which the injection was also made into 
the nerve trunks as they leave the spinal canal. 

“The technic for parasacral injections is as follows: The two 
points of injection lie 1.5 to 2 cm. from the median line to the right 
and left of the sacrococcygeal articulation. Inspection of the inner 
surface of the sacrum shows that in the lower part, between the 
second and fifth sacral foramen, there is very little curvature to the 
bone, which makes it possible to push the needle forward in a 
straight line along the inner surface from the point mentioned to 
the second sacral foramen, without losing the contact between the 
point of the needle and the bone. Above the second sacral foramen 
the point of the needle must necessarily strike the bone and, there¬ 
fore, cannot be inserted farther. In the adult this point is 6 to 7 cm. 
from the point of entrance, not taking into consideration the soft 
structures. 


120 


GENERAL TECHNIC 


“The patient is now placed in the lithotomy position and the 
needle inserted in a direction parallel with the inner surface of the 
lower half of the sacrum; with the point of the needle the edge of 
the sacrum is sought for. Feeling the way past the edge of the 
sacrum the needle is pushed along the inner surface of this bone 
parallel to its median plane until it strikes the bone at the depth 
mentioned. The entire distance from the second to the fifth sacral 
foramen is injected with 20 cc of a 1 per cent novocain-suprarenin 
solution. No injection should be made until contact with the 
bone is felt. The needle is now drawn back to the edge of the 
sacrum and is directed at a small angle toward the innominate line, 
always pushing it parallel to the median plane. In this direction 
the needle penetrates deeper than before, until it again strikes the 
bone above the first sacral foramen at a distance of 9 to 10 cm. from 
the point of entrance, the soft parts not being taken into considera¬ 
tion; at this point 20 cc of 1 per cent novocain-suprarenin solution is 
injected. The final injection of 5 cc of the solution is made between 
the rectum and the coccyx from the same point of entrance. The 
same injection is made on the opposite side; altogether 100 cc of the 
solution are required. The needle must be 12 cm. long. The author 
makes this injection without the aid of a guiding finger in the 
rectum, as the empty bowel is not easily injured and evades the 
needle. If the operator is doubtful on this point, then the position 
of the needle should be controlled by the finger, especially in making 
the injection to the first sacral nerve. This method has been used 
in prostatectomies, in operations for complete prolapse of the 
uterus, both with and without artificial fixation of the uterus, in 
extirpation and resection of the rectum for carcinoma, the rectum 
being painlessly dissected as far as the flexure. 

“The anesthesia extends higher up than Lawen’s sacral anesthesia 
and affects the same segments. Iff consequence of the blocking 
of the posterior cutaneous femoral nerve, the skin of the posterior 
surface of the thigh always becomes insensitive as far as the popliteal 
space. The sphincter ani is necessarily paralyzed. The urethral 
prostate and bladder are both totally insensitive. Anesthesia of the 
parietal peritoneum does not extend high enough for an extirpation 
of the uterus, for, as is well known, a high lumbar anesthesia is 
necessary for this purpose. That part of the peritoneum supplied 
by the sacral plexus alone is confined to the floor of the pelvis. 
Parasacral anesthesia is a most reliable form of anesthesia; more so 
than sacral and without secondary effects. This reliability is 
attributed to the fact that the course taken by the needle is deter¬ 
mined by its point of contact with the bone.” 


TRANS-SACRAL ANESTHESIA 


121 


TRANS-SACRAL ANESTHESIA 1 (Fig. 28). 

Ihe method of introducing trans-sacral injections according to 
Pauchet is as follows: 

I lace the patient in the extended posture with the face down¬ 
ward. Draw a line from one iliac crest to the other. Identify and 
mark the points over the sacral cornua to each side of the sacral 
hiatus and then draw a line directly over the median line of the 
spinous processes from the level of the iliac crests downward. 
Next locate points 4 cm. to each side of the midline along the line 
connecting the iliac crests and from these points pass two lines 
directly over the two sacral cornua. These two lines will pass 
directly over the two rows of sacral formina. Commencing at the 
top, the first sacral foramen is found on the line directly opposite 
the tip of the spinous process of the fifth lumbar vertebra. At a 
point 31 cm. (35 mm., or the breadth of a thumb) below on the same 
line will be found the second foramen. Two and one-half cm. 
(25 mm., or approximately the breadth of a thumb) farther down 
is the third; 2 cm. (20 mm. or the width of the little finger) still 
farther down is the fourth; and 1| cm. (15 mm. or approximately 
the width of the little finger) below this is the fifth. The anatomical 
landmarks are as follows: The first sacral foramen is opposite the 
fifth lumbar spinous process; the second foramen is just medial to 
the prominent postero-inferior spine of the ileum, and the fifth 
sacral foramen is exactly outside the sacral cornua. The first 
foramen is about 35 mm. from the median line; the second, 30 mm.; 
the third, 25 nun.; the fourth 20 mm.; and the fifth 15 mm. The 
skin is then prepared with iodine and alcohol in the usual way and 
Pauchet makes five dermal wheals on each side at the points over- 
lying the sacral foramina, using a fine needle. (The author’s 
technic differs in that he makes but one painful wheal and from this 
one makes the remaining ones by the subintradermal method. (See 
Fig. 31, page 149.) Then commencing at the top with a 9 cm. 
needle the operator can readily find the foramina! opening by 
feeling about with the point of the needle and he can tell he is in by 
suddenly sensing the absence of resistance, as well as noting when 
the patient complains of a disagreeable sensation in the abdomen 
or legs as the needle pierces the nerves. The needle should penetrate 
to a depth of about 25 mm. for the first foramen, 20 mm. for the 
second, 15 mm. for the third, 10 mm. for the fourth and 5 mm. 
for the fifth. Five cc of a 1 per cent solution are injected at each 
opening.” 


1 Shervvood-Dunn: Regional Anesthesia, Technic of Victor Pauchet, 1920, p. 207. 


122 


GENERAL TECHNIC 


“The operation can be begun in about fifteen minutes and the 
anesthesia lasts from one and a half to two hours. The injections 
anesthetize the labia, prostate, bladder, rectum, anus, uterus, and 
the skin of the posterior surface of the thigh.” 

PARAVERTEBRAL ANESTHESIA. 

The following is a liberal translation from the work of Prof. 
Heinrich Braun 1 regarding paravertebral anesthesia: 

“The nervi thoracales pass out of the intervertebral foramina 
of the thoracic vertebrae and soon after their exit give off connecting 
branches, the rami communicantes to the sympathetic nervous 
system, and then divide into anterior and posterior divisions. The 
latter go to the muscles of the back and innervate the skin to the 
right and left of the midline. (The anterior divisions are distributed 
chiefly to the parietes of the thorax and abdomen.) 

“The labors of Neumann and Kappis have determined beyond 
dispute that the sympathetic nervous system alone is the carrier 
of sensation in the abdomen. The rami communicantes of the 
sympathetic nervous system are the pathways through which the 
sensory nerve fibers that originate in the sympathetic ganglia and 
plexuses are conducted to the spinal nerves, the cord and the brain. 
This is done in part by continuity and in part by means of the nervi 
splanchnici. In the pelvis this role is taken over by the autonomic 
nervus pelvicus. 

“The idea of paravertebral blocking was originated by Sellheim 
(1905), who attempted to interrupt the eighth to the twelfth inter¬ 
costal nerves, as well as the iliohypogastric and ilioinguinal at their 
points of exit from the vertebral column. This was done for the 
purpose of doing abdominal operations, giving accurate directions 
for passing the needles. 

“The technic calls for the introduction of the needle 2 to 3 cm. 
lateral to the interspinous line until the vertebral arch is reached, 
gliding laterally over the edge of the arch between the transverse 
processes and then proceeding from 1 to 2 cm. farther, striking the 
nerves as they emerge from the foramina at the posterior surface of 
the vertebral arch. Sellheim’s attempts were indeed not without 
success but failed because the anesthetics obtainable at that time 
were not efficient. He intended, by the way, an intercostal anes¬ 
thesia in the sense above mentioned, for at that time nothing was 
known of the role played by the sympathetic nerves and the rami 
communicantes with regard to the conduction of pain sensation 
from the abdomen. This was demonstrated later by Kappis. 


1 5th edition, 1919, Chapter XIII, p. 320. 


PARAVERTEBRAL ANESTHESIA 


123 


Lawen (1911) again took up these attempts and named the 
procedure paravertebral anesthesia.’ He reports inguinal hernia 
operations and one nephrectomy, having interrupted the lower 
dorsal and upper lumbar nerves. 

ihe practical experiences of Kappis and Finsterer affirmed that 
paia\ ertebral blocking of sufficient intercostal and lumbar nerves 
anesthetized not only the abdominal wall but the whole cavity as 
well, thereby giving complete relaxation of the abdominal parietes 
and motor paresis. 

“ During the past few' years paravertebral anesthesia had been 
employed quite extensively in abdominal surgery. Indeed, Siegel 
in reporting 1000 cases designates it the anesthesia of choice for all 
abdominal operations as well as for gynecological and vaginal 
operations in conjunction with parasacral anesthesia. The failures 
are said to be rare with this method, especially when both para¬ 
vertebral and parasacral are combined, and there is no doubt that 
the method is useful in doing laparotomies because a painless 
abdominal cavity and a relaxed abdominal w T all are obtained. 

“In the technic of paravertebral anesthesia it is important to 
block the rami communicantes and sympathetic nerves as w T ell 
as the spinal. For that reason the needle must be guided quite 
near the vertebral column. The best point of orientation for passing 
the needle to the body of the thoracic vertebra is the inferior border 
of the ribs and not the transverse vertebral bodies as preferred by 
some. Braun agrees with Siegel that it is not necessary and perhaps 
not even possible to locate any single nerve with the needle point, 
and the most efficient block is assured by ample infiltration of the 
region containing the nerves with a 0.5 per cent solution of novocain- 
adrenalin. The technic differs from the one described for inter¬ 
costal injections to a certain extent. A strip of skin 5 cm. lateral 
to the spinous processes is anesthetized and the lower border of the 
rib (twelfth) is found with the needle, which is then withdrawn a 
bit and directed mesially at an angle of 120 degrees for 2 cm. It 
follows the low r er costal border crossing the angle between the rib 
and transverse process. One may strike the transverse process, 
which can be avoided by withdrawing and raising the needle so that 
it passes in front of the same on reinserting. While inserting the 
needle one must begin injecting to avoid pain. A total of 15 to 20 
ec of the solution is injected into each space, and when this is done 
there occurs an almost continuous infiltration along the vertebral 
column so that fluid escapes from a needle, which is inserted in an 
adjoining space. The inferior border of the twelfth rib is usually 
taken as the starting point and the needle is left in position until the 
first lumbar is located. This is done by passing an 8 to 10 cm. 
needle through the anesthetized skin and aiming at the transverse 


124 


GENERAL TECHNIC 


process of the first lumbar vertebra. The lower border of the 
process is passed mesially and caudally 2 cm. and then 20 cc of 
the solution are injected. In the same way the second and third 
lumbar nerves, each 6 cm. lower, are blocked. The fourth and 
fifth lumbar nerves cannot be reached in this manner but they are 
unimportant with regard to abdominal sensation of pain. Next, the 
eleventh rib, then the tenth and so forth up to the fifth are injected 
similar to the twelfth.” 

The segmentary innervation of the abdominal organs by sensory 
nerve fibers may be outlined after the animal experiments of Kappis 
as follows: 


Stomach 

I Jpper small intestine 

Liver 

Spleen 

Lower small intestine 
Large intestine 
Kidneys 


Dorsal 6 and 7 

Dorsal 8 to lumbar segments 
Lumbar segments 
Dorsal 8 to 12 


Practically, this is of small importance because the lower and 
higher fields of innervation in the abdomen overlap. Therefore a 
considerable number of segments must be blocked to anesthetize 
any great part of the abdomen. Kappis concluded from embryo- 
logical evolutionary studies that the gut is innervated bilaterally 
in its entire course and one must therefore block bilaterally even for 
unilateral laparotomies. 


SPLANCHNIC ANESTHESIA. 

Posterior (Kappis).—With regard to the removal of sensations 
of the abdominal and other organs, Braun 1 makes the following 
observation and gives a description of Kappis’s method of establish¬ 
ing splanchnic anesthesia: 

“The most successful attempt to remove the abdominal sensa¬ 
tions of a circumscribed larger segment of the abdominal cavity in a 
simple and reliable manner without the aid of narcotics is founded, 
I believe, upon the fact that the sensory nerve fibers of pain for 
the upper abdominal organs (liver, gall-bladder, stomach, duodenum 
and the proximal small intestine) run exclusively in the course of 
nn. splanchnici to the spinal cord. 

“The n. splanchnicus major joins the vena azygos at the antero¬ 
lateral surface of the twelfth thoracic vertebra and passes between 
the crus mediale and crus intermedium diaphragmatis through the 


1 Local Anesthesia, translation by Shields, p. 354. 



SPLANCHNIC ANESTHESIA 


125 


diaphragm. 1 he n. splanchnieus minor either takes the same course 
oi it runs a little farther laterally through the diaphragm. Both 
nerves having entered the abdominal cavity lie alongside the 
aorta in the loose tissue under the insertion of the omentum minus 
in the posterior abdominal wall and at the level of the celiac artery 
pass into the celiac plexus. This region is accessible with the 
needle from behind as well as in front. 

1 he direction from behind has been described and used by 
Kappis. The manner of passing the needle is as follows: 

“The patient lies in a lateral position. A needle 12 cm. long is 
inserted into the skin at a point 7 cm. lateral to the line of the 
spinous processes and at the lower border of the twelfth rib and is 
then passed obliquely in the direction of the vertebral body. As 
soon as the needle has touched the vertebra it continues to feel its 
way past the body or centrum. A hen that is accomplished it 
should be passed 1 cm. farther. It rests now in or at the lateral 
insertion of the diaphragm to the vertebral body, where also the 
nervi splanchnici are situated. The same procedure is carried 
out on the other side. Kappis injects 20 to 40 cc of a 1 per cent 
novocain-suprarenin solution on each side and then passes farther 
downward upon the lateral aspects of the lumbar vertebrae and there 
again injects 15 to 20 cc of the solution. The abdominal wall is 
made insensible by these regional injections.” 

Braun further states: 

“ Kappis has executed more than 200 operations (most of them 
upon the stomach and gall-bladder) with this method and says that 
with increasing practice failures have seldom occurred.” 

In this connection it is interesting to note that Braun recommends 
proper preparation of the patient with scopolamin and states that 
this must not be omitted in cases in which splanchnic anesthesia is 
to be induced by the method of Kappis. 

Anterior Splanchnic Anesthesia.—Wendling was the first to 
make the suggestion to anesthetize the splanchnic region from the 
anterior root through the intact abdominal wall. Braun gives the 
following description of the Wendling technic: 

“Anterior Splanchnic Anesthesia (Wendling).— The point of 
entrance is found 0.5 cm. to the left of the middle line and 1 cm. 
below the extremity of the ensiform process. A needle inserted 
vertically at this point reaches usually at a depth of not more than 
6 cm. (having passed the liver and the free abdominal cavity) 
the retroperitoneal structures under the insertion of the lesser 
omentum. Wendling injected here 50 to 80 cc of a 1 per cent 
novocain-suprarenin solution and in 26 cases got a very good 
anesthesia of the organs of the upper abdomen—once a failure.” 

Braun further states that Wendling renders the abdominal 


126 


GENERAL TECHNIC 


parietes painless by regional infiltrations. Wendling warns one to 
beware of intravenous injection in the vascular regions, since he had 
novocain poisoning in one case because of injecting a vein uninten¬ 
tionally. 

Braun states: “I do not believe that Wendling’s method will 
find many imitators. Even granted that after Wendling’s experi¬ 
ments injuries of the gastro-intestinal tract are not to be feared, 
this is only met providing the organs lie in their normal positions 
but not when the stomach is displaced and adherent. In cases of 
old stomach ulcers the transverse colon may indeed lie under 
Wendling’s point of attack. However, in my opinion, in doing 
operations in the upper abdomen there is not any need to inject 
the nil. splanchnici before the abdomen is opened, for in the open 
it is done so much better, guided by the eyes and the palpating 
fingers. We have to remember that Dollinger, Finsterer, Hacken- 
bruch and others have already recommended for stomach operations 
to secondarily infiltrate the lesser omentum.” 

Braun, himself, prefers to establish splanchnic anesthesia through 
the anterior route. He further states: 

“In stomach operations I proceed as follows: After a real 
careful regional infiltration the abdomen is opened in the middle 
line. The left hepatic lobe is gently and carefully lifted up with a 
flat retractor. With the index finger of the left hand one feels for 
the anterior surface of the first lumbar vertebra, which is situated 
at the level of the ensiform process. One feels the pulsating aorta, 
which is pushed over to the left. The finger is resting on the right 
lateral part of the anterior surface of the vertebral body, covered 
at this place only by a thin layer of soft parts, the insertion of the 
diaphragm and the posterior peritoneum. 

“ Next one passes a needle 12 cm. long along the finger against the 
bone. It should strike the bone immediately. In case it does not, 
then it has been guided wrongly. In this manner vessels cannot be 
injured, especially the vena cava, which lies aside farther to the 
right. However, precaution is to be used, as is observed also in all 
other regions of the body to change the needle a little if perhaps 
some blood escapes from it. If such is not the case, the left index 
finger is withdrawn and without changing the position of the 
needle 50 cm. of 0.5 per cent novocain-suprarenin solution is in¬ 
jected. 

“ In the same manner one finds with the right index finger the 
left antero-lateral surface of the first lumbar body and pushing the 
aorta aside to the right one guides the needle again along the finger 
and one injects another 50 cm. of the solution. In this way a very 
extensive infiltration is achieved of the anterior and lateral aspects 
of the vertebral column, i. e., the soft parts which cover it and 


SPLANCHNIC ANESTHESIA 


127 


which contain the nn. splanchnici and the large ganglia lying in front 
of the aorta. 

All these manipulations should be done gently and carefully. 
All pulling of the lesser omentum and spreading of the abdominal 
wound and any examination of the cavity should be particularly 
avoided before the injections have been made. In all the injections 
it is shown that the place where the solution shall be put is to be 
reached only by pushing aside the stomach, the lesser omentum and 
the aorta. It appears almost impossible to strike it through the 
intact abdominal wall, as Wendling does, without uncontrollable 
injuries being done.” 

The author agrees with Braun that the anterior splanchnic 
anesthesia of Wendling will probably never become popular. The 
posterior splanchnic anesthesia of Kappis is undoubtedly efficient, 
and when indicated will prove decidedly useful. 

The anterior method of Braun, however, has so many advantages 
over the other two that it seems probable that it will prove the 
method of choice with many surgeons. A modification of the 
method of Braun has given gratifying success in obtaining 
anesthesia, permitting one to do most of his abdominal work 
without pain to the patient. 

The author s method of establishing anesthesia within the abdomi¬ 
nal cavity is predicated first upon the establishment of an efficient 
anesthesia of the abdominal wall and second upon the use of a surgi¬ 
cal technic which decreases to a great extent the demand for com¬ 
plete anesthesia within the peritoneal cavity plus the addition of but 
a small amount of solution retroyeritoneally. In other words, by 
adopting a surgical technic which would meet the demands of the 
situation, by observing the effect of the manipulation of the intra- 
peritoneal organs and structures, and by adding extremely small 
amounts of local anesthetic solutions the writer has been able to 
carry out these operations. Exposure has been the sheet anchor 
and it is felt that any operation within the peritoneal cavity is 
entirely possible provided the nerve supply of the region proximal 
to the organs and tissues to be attacked may be visualized. The 
form of splanchnic anesthesia employed is a simple subperitoneal 
infiltration made along the path of the splanchnic nerves which 
one desires to interrupt. A simple infiltration beneath the peri¬ 
toneum in the region of the cystic duct, for instance (Tig. 29), will 
result in almost immediate anesthesia of this region so complete 
as to permit the carrying out of any operation upon the gall-bladder 
and ducts. After anesthetizing the abdominal wall it is entirely 
a matter of exposing the region, and the method of obtaining this 
exposure is detailed on page 397. 

The various steps in the operations are dependent upon each other 


128 


GENERAL TECHNIC 


and the success of each is largely dependent upon the preceding 
steps. Thus if the abdomen is opened without obtaining a negative 
intraperitoneal pressure it will be impossible to obtain the desired 
exposure and a simple anterior splanchnic block similar to that 
described will be impracticable. The success of the method will 
therefore depend largely upon one’s ability to master the details 
and to meet the demands of the portion of the operation which 
precedes the time for establishing anterior splanchnic anesthesia. 
It has not been found necessary, nor has it seemed desirable to use 
the more complicated methods to any extent. Although their use 
is justified in all cases in which the necessity arises, the demands 
of the situation can usually be met by these means. More detailed 
descriptions will be found in the discussions of Surgery of the 
Abdomen, Chapters XIII to XVIII. 



To illustrate the possibilities of the method just described the 
following statistics are offered, giving the percentage of cases upon 
which the author has been able to operate successfully under 
infiltration of the abdominal wall, combined with his surgical technic 
and method of anterior splanchnic anesthesia. These statistics 
include patients of all ages, children as well as adults, and cover the 
period during which the present technic has been employed. 

Of 145 pelvic operations of all descriptions started under local 
anesthesia, 130, or 90 per cent, were finished with the same. In 15 
general anesthesia was added. 

Of 140 gall-bladder operations started with local anesthesia, 













BRACHIAL ANESTHESIA 


129 


130, or 95 per cent, were finished with the same. In 10 cases 
general anesthesia was added for varying lengths of time. 

Of 220 appendix cases, 48 per cent, of which were acute or sub¬ 
acute, started under local anesthesia, 215 or about 98 per cent, 
were finished with the same. In 5 cases general anesthesia was 
added. 


HANDLING THE ABDOMINAL VISCERA. 

The lifting and handling of the abdominal viscera by gloved 
fingers or gauze is difficult. In deep wounds the hand will usually 
completely obstruct the view unless the viscus is dislocated and 
brought to the surface. The slippery organs are difficult to hold 
in the gloved hand and, not uncommonly, gauze is used in order to 
overcome this difficulty. Some form of long, rubber-tipped forceps 
is desirable for this purpose. They do not obstruct the view, 
the various organs can be effectively manipulated and trauma is 
largely eliminated by their use. Fig. 26, page 110, illutrates a type 
of forceps which is satisfactory for this purpose. Here, as else¬ 
where, the use of long delicate instruments allows the handling and 
distinguishing of the tissues and to depend upon direct visualization 
rather than the sense of touch. In hypertrophic pyloric stenosis, 
for instance, it is often extremely difficult to elevate the hyper¬ 
trophied pylorus which frequently lies posterior to the pyloric antrum 
and deep beneath the liver edge, provided the fingers alone are 
depended upon. On the other hand, with the establishment of a 
perfect negative pressure (See page 147) and the use of long deli¬ 
cate forceps this structure may be elevated into the abdominal 
incision with the utmost ease. 


BRACHIAL ANESTHESIA (Fig. 30). 

For work upon the upper extremity brachial anesthesia has been 
employed extensively. When the nerve trunks are reached by the 
needle point this form of anesthesia is certain, complete and immedi¬ 
ate. With a little experience one may learn to establish brachial 
anesthesia with but a small margin of error. However, its estab¬ 
lishment requires the cooperation of the patient, who must report 
to the surgeon when paresthesia appears. Another shortcoming of 
the method relates to the greater difficulty in striking the brachial 
plexus with the patient in the recumbent position, and as many 
patients cannot assume the upright posture, this factor becomes a 
real drawback. 

Brachial anesthesia will last for approximately one and a half 
hours and will therefore allow one to carry out almost any manipula¬ 
tion or operation upon the upper extremity. 

Fig. 30 shows the relation of the brachial plexus to the surround- 

9 


130 


GENERAL TECHNIC 


ing structures and also the direction of the needle. r lhe introduc¬ 
tion of the needle should be preceded by the establishment of an 
initial wheal at the midpoint of the clavicle. 

The following is a description of the technic of Kulenkampff 
(from Braun) : l 



“ It is advisable, whenever possible, to have the patient in the 
sitting posture while being anesthetized. The patient needs no 
previously administered opiate, but he should certainly be informed 
of the paresthesia, which radiates to the fingers and which will 
arise when the needle penetrates the plexus, and he should be 
instructed to state when he feels these sensations. This is the 
only way to positively determine when the needle has reached the 
right spot. The next step is to palpate the subclavian artery, 
which is done by making gentle pressure with the finger. In 
many cases the pulsation is visible more often to the right than to 


1 Local Anesthesia, Brachial Anesthesia, Kulenkanipff’s Method, p. 352, 









brachial anesthesia 


131 


the left, which may be explained by varying anatomical relations. 
A wheal is placed directly outward from the spot where the artery 
disappears behind the edge of the clavicle. The spot almost 
without exception will correspond to the middle of the clavicle. 
At this same point, as a rule, a downward prolongation of the 
external jugular vein, which is usually visible, also crosses the 
clavicle. Here we insert a fine needle 4 to 6 cm. long, without 
syringe, in the direction which it should take to strike the spinous 
process of the second or third dorsal vertebra. The plexus lies 
rather close to and under the fascia. As soon as the needle touches 
it, radiating paresthetic sensations are complained of in the fingers 
supplied by the median nerve which lies superficially, and of the 
radial nerve which lies deeper and posterior to the median nerve. 
If at a depth of 1 to 4 cm. the first rib is felt, it indicates that the 
plexus must lie more superficially. If paresthesia is not obtained 
at once, it must be sought by slightly changing the position of the 
needle. Very often, from an unnecessary anxiety about the sub- 
clavian artery, the needle is inserted too far outward. If blood 
flows from the needle, its direction must be changed. As soon as 
paresthesia occurs, attach the syringe to the needle and inject 10 cc 
of a 2 per cent novocain-suprarenin solution. If paresthesia 
evidences itself in the region supplied by the median nerve, a part 
of the solution should be injected a few millimeters deeper. Finally, 
10 cc more are injected so as to be distributed in the immediate 
surroundings, the direction of the needle being very slightly changed 
during this injection. 

‘‘The operator should not make the injections before the pares¬ 
thesia occurs. If there is a pronounced paresthesia of the median 
as well as the radial nerve, it indicates that a complete sensory and 
motor paralysis of the arm will occur after one to three minutes. 
It is usually necessary to wait ten to fifteen minutes, but if after 
this length of time the paralysis is not complete, it will be advisable 
to make another injection of 5 to 10 cc of a 4 per cent novocain- 
suprarenin solution. Paresthesia will not be felt after this latter 
injection and results are more or less uncertain.” 

The patient is quite likely to change position during the intro¬ 
duction of the needle and the search for the bundles of nerves. 
The head is apt to be rotated or the patient may elevate the shoulder 
upon the affected side. It is well repeatedly to caution him during 
the introduction of the needle so that the relations of the parts be 
not disturbed. When making the injection the fluid should be 
introduced slowly so that the nerve structures will not be torn. As 
a rule about two minutes should be allowed to elapse during the 
introduction of 5 cc of solution, 


132 


GENERAL TECIINIC 


NARCO-LOCAL ANESTHESIA. 

(See Chapter III, Page 72.) 

When doses of narcotics of sufficient size are administered to 
establish the condition known as “ twilight sleep” the method should 
he designated “narco-local” anesthesia, and a careful distinction 
should be made between this condition and one where the faculties 
remain alert and the preliminary medication has been given merely 
for its “tiding over” effect. Two articles describing this method 
appeared upon the same date, May 1, 1910: one from the Freiburg 
Clinic by Kroenig and Sieger 1 and the other by the author. 2 

Various combinations of drugs have been used for the purpose 
of establishing “twilight sleep.” However, the author has used but 
few: morphin and hyoscin, morphin and scopolamin, morphin and 
magnesium sulphate and morphin and atropin, or some of the 
substitutes of morphin such as pantopon. 

The use of morphin and scopolamin was begun in 1904, at which 
time practically all surgery was done under general anesthesia. 
1 )ivided doses were usually used and the total amounts have varied 
from | gr. morphin and 1-400 gr. scopolamin to J gr. morphin and 
jr-j gr. of scopolamin. The size of the dose must depend upon a 
number of circumstances. The age, weight and temperament of the 
patient are influencing factors. However, a more important con¬ 
sideration is the surroundings in which the patient is placed at the 
time the drugs are given. The matter of assuring the patient a 
perfect night’s rest on the night preceding the operation is also an 
influencing factor. We have already referred to the absence of 
unnecessary fussing with the patient on the morning of the opera¬ 
tion. If narco-local anesthesia is to be employed the drugs should 
be given hypodermically and in repeated fractional doses, the first 
dose being given as soon as the patient awakes. The curtains 
should be drawn, the room made quiet and visitors excluded. In 
transporting the patient to the operating room the utmost gentle¬ 
ness should be employed (see Chapter III, page 72). Music is 
a valuable adjunct in these cases. The amount of the drugs to be 
used cannot be specifically stated here. Usually the responsibility 
for this is placed upon the psycho-anesthetist, who watches the 
patient from time to time and orders the medication in doses 
sufficient to bring the patient to the operating room in the condition 
desired. Experience indicates that massive doses should not be 
used and the effect of the narcotic should not be depended upon for 
the production of anesthesia. It is unnecessary to bring the patient 


1 Surg., Gynec. and Obst., No. 5, 12. 524. 

2 Farr, Robert Emmett: Narco-local Anesthesia, St. Paul Med. Jour., May, 1916. 


SYNERGISTIC ANESTHESIA 


133 


into a condition of deep sleep and but small doses are required in 
order to make him more or less oblivious to what is transpiring, 
especially if other details are carefully looked after and irritation 
avoided. In one series of cases (300 in number) in which a complete 

twilight sleep was attempted it seemed that with proper attention 
to detail it was unnecessary to deeply narcotize prospective candi¬ 
dates for operations under local anesthesia, at least with any 
combination of drugs which has been presented up to the present 
time, the performance of operations under local anesthesia with¬ 
out pain to the patient makes the employment of heavy doses of 
narcotics more or less unnecessary, and experience seemed to show 
that the psychic demands are not sufficiently great to require their 
use in exceedingly large doses. 

In dealing with extremely nervous patients or those with toxic 
thyroids, preliminary medication becomes a somewhat important ally, 
especially in the cases with thyroid complications (see Chapter VIII, 
page 243; Chapter III, page 72). In these patients the drugs are 
administered in doses of sufficient size to eliminate the psychic 
disturbances and to make the patient more or less oblivious to what 
is going on about him. However, the amount required for this 
purpose is maintained at a minimum by proper handling of the 
patient and proper control of his surroundings. The trial trips to 
the operating room which are made on days previous to the operation 
also serve to cut down the amount of preliminary drugging which is 
required in order to obtain the desired effect. 

SYNERGISTIC ANESTHESIA. 

As a substitute for scopolamin and morphin, Gwathmey, 1 has 
made an extensive study of the synergistic action of magnesium 
sulphate when combined with morphin sulphate and given hypo¬ 
dermically. He concluded from animal experiments and clinical 
observations at the Presbyterian Hospital, New York, that (1) 
general analgesia cannot be obtained with morphin sulphate and 
magnesium sulphate; (2) that morphin sulphate gr. | and 2 cc 
of a 25 per cent magnesium solution repeated three times hypo¬ 
dermically at short intervals as of one-half hour just before operation 
gave a more complete analgesia and relaxation with nitrous oxide 
and oxygen than could be obtained with ether, that the amount of 
oxygen that could be used was greater (35 per cent plus) when the 
synergistic method was followed and (3) that the magnesium sul¬ 
phate so used with morphin increased the effectiveness of the 
latter from 50 to 100 per cent. 


1 Synergistic Colonic Analgesia, Jour. Am. Med. Assn., January 22, 1921, 76, 222. 


134 


GENERAL TECHNIC 


The author has used this combination of drugs somewhat exten¬ 
sively during the past two years, and while he believes its use en¬ 
hances the effect of the morphine somewhat, he cannot satisfy him¬ 
self that it does so to the degree which Dr. Gwathmey suggests. 
He finds that some caution is necessary in regard to the manner 
of administration. A number of sloughs have occurred in cases in 
which the nurse injected the magnesium sulphate intradermally, 
and even subdermally. The hypodermic injection should be made 
entirely subdermally and not intradermally and preferably intra¬ 
muscularly. Furthermore, it should be given slowly. 

The experience of the past six years has not clarified the narco- 
local situation to any extent. The writer is still of the opinion that 
this form of anesthesia, especially if followed by small doses of 
scopolamin and morphine for two or three days after operation, will 
give the patient the greatest comfort of any method produced to 
date. In fact, it can be made to practically eliminate all the dis¬ 
agreeable subjective features connected with an operation. It 
seems that no other form of anesthesia compares with it. The 
relaxation, quiet, absence of engorgement of the tissues and the 
time allowed for the work all combine to make this the most ideal 
method of anesthesia yet evolved. However, the question of its 
safety submitted in the paper referred to has not been answered 
with satisfaction. Too many reports indicate that this large 
dosage is dangerous and the literature contains many reports of 
deaths following the administration of scopolamin in large doses. 
In Chapter 114 this subject is referred to more in detail under the 
pharmacology of the drugs used as a preliminary to local anesthesia. 

To summarize, it may be said that preliminary medication bears 
much the same relation to local as it does to general anesthesia and 
is therefore to be considered as a source of solace to the patient in 
either case. The indications for its use are about as marked in 
one as in the other. As an adjunct it does reduce the amount of 
general anesthesia used. It does not materially alter the quantity 
necessary when local anesthesia is employed. Its main advantage 
is in tiding the patient over the hours immediately preceding the 
operation, and this event assumes much the same importance in all 
cases and is as necessary when general as when local anesthesia is 
used, although this fact is apparently not generally recognized. 
Massive doses of narcotic drugs given for the purpose of replacing 
local or general anesthesia are too dangerous to be recommended. 
Moderate doses of standardized drugs, when carefully controlled, 
are of the utmost importance and their advantage probably largely 
offsets the disadvantage. 


THE PREPARATION OF A PATIENT 


135 


THE PREPARATION OF A PATIENT FOR AN OPERATION 
UNDER LOCAL ANESTHESIA. 

Psychic.—The preparation of a patient for operation under local 
anesthesia involves many considerations both psychic and physical. 
One must remember that at the present time local anesthesia is 
under a decided handicap as regards the mental attitude of the 
prospective patient. This handicap is no different from that under 
which general anesthesia labored before people had become 
accustomed to its use and the degree varies with the education of 
one’s clientele. Obviously, the patient who has never heard of the 
method, or one who has heard nothing but unfavorable reports 
concerning it, will approach an operation with prejudice against it. 
The same condition prevails in the patients who have undergone an 
operation under so-called local anesthesia which was a failure. 

Attention has already been called to the necessity of paying 
attention to every detail which will reduce or eliminate the causes of 
irritation and worry on the part of the patient from the time he 
comes under treatment; also that the preliminaries, such as shaving, 
douching, bathing and saying farewell to friends, should be disposed 
of the day before the operation, if possible. The night preceding 
the operation should be one of rest for the patient if it is at all 
possible to attain this desideratum. A wakeful and uneasy night 
is a potent factor in disturbing the tranquility of a patient. The 
writer does not hesitate to give a liberal dose of some somniferent, 
such as veronal, trional or even morphin, when pain presents, to 
every patient the night preceding operation. 

The manner of handling patients during the hours which just 
precede the operation is one of the perplexing problems lor all who 
have made a study of the patient’s comfort and have endeavored to 
allay the anguish of anticipation with which most people are to a 
greater or lesser degree afflicted. It is well to instruct the nurses 
to avoid the usual routine of awakening the patient when he is 
having a sound sleep and to omit the ordeal of a bath or rub to 
which he is unaccustomed. Instead the patient is allowed to sleep 
until he requests some service. He is given to understand this the 
night before and many patients will sleep quite late in the morning 
if undisturbed by the night-nurse, who is usually much like the 
obliging Pullman porter who gets the passengers up sufficiently early 
so he may have his work cleaned up when the train pulls in. A 
light breakfast, consisting largely of fluids, but depending, of course, 
upon the nature of the operation to be performed, may be allowed. 
The friends are usually not allowed to see or converse with the 
patient and as a rule the shedding of tears, wailings, expiessions of 
sympathy as well as advice and fond farewells are excluded from the 


136 


GENERAL TECHNIC 


preoperative program. The morning paper, prayer-book or other 
reading matter are not objectionable unless preliminary narcotics 
are administered. In such cases the shades are drawn, the doors 
closed and every effort made to have the patient doze away the 
hours which otherwise might pass disagreeably, and at a cost to the 
patient’s economy which as yet have not been measured or 
calculated. 

THE APPLICATION OF REGIONAL ANESTHESIA. 

Both venous and arterial anesthesia have points of excellence 
and under certain conditions give satisfactory results. 

Venous anesthesia is a strong competitor of brachial anesthesia 
for producing anesthesia of the region of the elbow joint. 

Arterial anesthesia has limited advantages, although it may be 
indicated occasionally in work upon the extremities. Its employ¬ 
ment necessitates an exposure of a vessel supplying the part, which 
is more or less of a disadvantage. 

Regional anesthesia finds its most appropriate fields in the 
work upon the jaws, mastoid, neck, upper extremity, thorax and 
inguinal canal. Even in these localities, in some instances it must 
be reinforced by infiltration anesthesia, except perhaps in the case 
of the trigeminus nerve and the brachial plexus. The blocking of 
the trigeminal at, or just distal to, the Gasserian ganglion is a proced¬ 
ure which gives absolute anesthesia. However, we have found 
that with an infiltration anesthesia about the area to be operated 
upon, combined with infiltration in the course of the branches of 
the nerve, a satisfactory anesthesia may be obtained (Figs. 49-58). 
In this way we avoid the nausea and vomiting and possible danger 
of the intracranial injection and reduce the margin of error which 
exists, even in the hands of the most expert, in reaching the ganglion. 
The blocking of the inferior dental nerve may be accurately done 
and it has almost no margin of error. In the tonsillar operations 
regional blocking is desirable in order to avoid obscuring the field 
of operation, which results from infiltration of the pillars. Here 
the subcapsular infiltration is also acceptable. In all work upon 
the neck the cervical nerves should be blocked but the anesthetic 
should be reinforced by a subdermal infiltration along the lines 
of incision and the field of operation should be circumscribed 
subdermallv as well. 

Nothing can be more satisfactory than brachial anesthesia which 
was first used by Crile, who exposed the nerves before injecting, a 
technic which was simplified by Kulenkampff (Fig. 30, page 130). 
The anesthesia is immediate, certain and easy to induce. The 
amount of solution required is small. However, in order success- 


DIRECT INFILTRATION—REGIONAL ANESTHESIA 137 


fully to carry out this procedure, one must have the full and intelli¬ 
gent cooperation of the patient, and this naturally eliminates this 
form of anesthesia in a certain percentage of cases. Children and 
nervous, ignorant or unreasoning adults cannot give the surgeon 
the information regarding the contact of the needle point with the 
nerve bundles upon which the success of this procedure so largely 
depends. Anesthesia may be obtained without the cooperation of 
the patient by making an infiltration in the region of the plexus 
instead of definitely transfixing the nerve bundles, but on account 
of the close proximity of the subclavian vessels one will prefer to 
make a transverse infiltration block of the limb lower down, as 
shown in Fig. 99, page 274, or to employ venous anesthesia. 

In work upon the chest, regional anesthesia is of much value. 
The bony landmarks render the locating of the nerves easy and 
certain, and the margin of error is small. The use of the method 
in the operation for the radical removal of the breast has made this 
method a routine procedure and by its use the author has been 
enabled to perform this operation painlessly under local anesthesia. 
In the benign diseases of the breast, on the other hand, infiltration 
anesthesia is most satisfactory in our hands. 

Thoracotomies, costectomies, and the like, are best done under a 
combined regional and infiltration anesthesia. 

The operation for inguinal hernia is best done under regional 
block as an infiltration would obscure and interfere with the identi¬ 
fication of the tissues; but even here the time may be greatly 
shortened by employing a subdermal infiltration along the line of 
the proposed incision, (Fig. 171, page 404). 

In work upon the hip, for example, the nerve supply is best 
reached by an infiltration anesthesia, while lower down “infiltration 
block” may be used. The femoral, superficial external peroneal and 
anterior tibial are easily located and blocked. However, the 
blocking of the sciatic is not easy, and the “ spearing” for the other 
nerves is not the simplest thing in the world. The writer much 
prefers a transverse block by the infiltration method, shown in 
Fig. 100, page 274, making a special effort to deposit a generous 
amount of the solution near the location of the larger nerve trunks. 


DIRECT INFILTRATION AND REGIONAL ANESTHESIA 

CONTRASTED. 

In general terms the methods which are available to the surgeon 
are some form of infiltration or regional anesthesia. The merits 
of these two methods it seems wise to evaluate somewhat at length. 
The adoption of local anesthesia will be influenced, to some degree, 
by the choice of methods on the part of surgeons who use local 


138 


GENERAL TECHNIC 


anesthesia in the future. On this account the following discussion 
is introduced: 

There is no question that the ideal method of producing local 
anesthesia, looked at from a purely academic standpoint, is by the 
regional method. It sometimes has the advantage of minimizing 
the amount of solution used. The field of operation is not disturbed. 
Its successful exhibition shows such a clear knowledge of anatomy 
on the part of the surgeon who employs it successfully and its 
results are so spectacular that it at once appeals to the observer, 
as well as to the reader, as the most precise, scientific, safe and 
therefore the most desirable method of securing local anesthesia. 
Indeed, if it were not for some of the shortcomings which this 
method presents in actual practice it would leave little to be 
desired. 

However, one must consider conditions as they present themselves 
rather than from the standpoint of the ideal. It is perfectly 
obvious that the vast majority of surgeons fail to avail themselves 
of the benefits of local anesthesia, although these benefits are 
perfectly apparent, and indeed are admitted by most surgeons at 
the present time. Why, then, do the majority of surgeons fail to 
make use of these advantages? It is believed that one of the most 
potent reasons is the fact that the methods thus far presented are 
rather difficult for the average surgeon to acquire, and that even after 
their acquisition they are found to be tedious and irksome and unless 
the technic be especially well mastered the results are liable to be 
disappointing. 

While it is unquestionably desirable to employ only a minimum 
amount of solution in each case, many other important factors 
present themselves for consideration. A sufficient amount of 
solution to produce analgesia must be used. The solution should 
be injected in such a manner that the patient is caused a minimum 
amount of discomfort while the injection is being made. (This 
applies not only to the actual introduction of the needle and the 
solution but to the manner of preparing special fields, as when 
regional anesthesia is used.) The element of time is important and 
the amount of time consumed should therefore be reduced to a 
minimum on account of its advantage to the surgeon as well as to 
the patient. The expenditure of energy on the part of the surgeon 
should be as slight as possible. 

While the first of these requirements—the establishment of anal¬ 
gesia—is an absolute necessity and admits of no half-way methods, 
the importance of time and expenditure of energy is more or 
less relative; these factors, however, must be reckoned with in the 
competition offered by general anesthesia. In this competition 
with general anesthesia it must be remembered that the matter of 


SIMPLIFYING THE TECHNIC OF LOCAL ANESTHESIA 139 


administering the anesthetic, when local anesthesia is used, often 
becomes the duty of the surgeon himself and cannot as a rule be 
detailed to a subordinate. It is therefore desirable that the details 
ol the actual administration be simplified as much as possible and 
in addition that the acquisition of the requisite training be simplified 
and all complicated and difficult methods be eliminated whenever 
less complicated ones will answer the purpose. Unquestionably 
the method which is most easily acquired and is the simplest of 
execution and the most devoid of complicated details is that known 
as direct infiltration in the region where the incision is to be made. 
With the proper equipment this method of producing analgesia 
possesses the attributes of speed, painlessness and accuracy, and 
demands the minimum outlay in energy and training on the part 
of the surgeon—extremely important points in relation to the 
question of the more universal adoption of local anesthesia. 

Even where regional anesthesia is used we find it more satis¬ 
factory to make what I have designated as “infiltration block" 
than to endeavor to accurately place the needle point upon or within 
the nerve tissue. The trigeminus, brachial plexus and the sciatic 
nerve may be transfixed by the needle, but in the case of most of the 
other nerves we prefer to deposit a liberal amount of the solution 
in the region where the nerve is known to lie. In so doing less 
accuracy is required and, in my experience, the results are more 
certain. The details relating to this method will be further con¬ 
sidered in the respective discussions of operations upon the various 
regions of the body. 


DESIRABILITY OF SIMPLIFYING THE TECHNIC OF LOCAL 

ANESTHESIA AND SOME ADVANTAGES OF INFILTRATION 

ANESTHESIA. 

The future development and the more universal use of local 
anesthesia will depend to a great extent upon our ability to make the 
technic so simple and easily acquired that it will be more readily 
available to surgeons than is now the case. I ndoubtedly most 
surgeons could master the technic of regional anesthesia would they 
but give it the required amount of attention. But even many of 
those who recognize its advantages consider that the expenditure 
necessary in order to become expert in the work is too great. Even 
the expert at times grows tired, as Hertzler says, “ of spearing for 
nerves.” The novice certainly becomes easily discouraged and 
is apt to forsake the method long before he has acquired sufficient 
skill to return him much satisfaction. Even from the patient s 
standpoint the technical difficulties of making multiple iier\e 
blocks are annoying and the reports given by some oi these patients 


140 


GENERAL TECHNIC 


constitute one of the cogent reasons why local anesthesia is at times 
in bad repute. The easier the induction of local anesthesia is 
made for the surgeon, the greater the speed with which it is done, 
the less the patients are disturbed by its administration, the less 
pain they suffer, and the more easily the technic is acquired the 
more satisfactory will the use of this method be found. 

Take, for instance, the operation for the removal of the appendix: 
Should the patient first be turned upon his face or left side and have 
his back prepared for a paravertebral injection and have an attempt 
made to spear the nerves supplying the region of the proposed 
operation, then change his position and have a new field prepared 
and the operation begun after the delay of some fifteen minutes? 
or, should the patient be placed in position for operation and only 
one field prepared, the anesthetic introduced, utilizing only two or 
three minutes, and the operation be begun at once? Anesthesia 
will be equally good with either method, but, on the one hand, 
much time has been consumed, the patient has been repeatedly 
pricked by a needle in an unanesthetized area, two fields have been 
sterilized instead of one and there has been demanded of the surgeon 
a minute, technical knowledge which can be gained only by much 
work upon the cadaver and repeated attempts upon the living sub¬ 
ject. Again, one might ask “What is the objection to direct infil¬ 
tration in such a case?” The solution does no harm to the tissues, 
the difference in the amount used is insignificant, the tissues are 
in no way obscured by its use, and after comparatively few attempts 
the novice may acquire a working knowledge of the method once 
it is properly explained and demonstrated to him. 

During recent years, upon three different occasions, the author 
demonstrated to visiting surgeons that the novice can master the 
technic of infiltration anesthesia with comparative ease. The 
argument was advanced that inasmuch as he had concentrated 
upon this work for many years, it appeared easy and simple to him, 
but that others would be unable to do the work with satisfaction 
without prolonged and intensive training. On each of these 
occasions it so happened that the assistant had been in service 
not to exceed six weeks, and had never performed an appendi- 
cectomy. In order to prove the point, the assistant was ordered 
to administer the anesthetic and to proceed with the operation. 
In each case the anesthesia was classed as “ideal” and was satis¬ 
factory in every way. None of these young men had assisted in 
more than five similar operations and no special effort had been 
made to teach them the technic, and yet each found himself equipped 
to perform an appendicectomy under local anesthesia after this 
brief period of training. It is improbable that this would have held 
true had regional methods been employed. It is not wished to 


detract in any manner from the excellent and deserved standing 
which regional anesthesia undoubtedly enjoys and the author is 
unreservedly in agreement regarding its possibilities. Yet there are 
a great many operations which lend themselves to the use of infiltra¬ 
tion anesthesia, and for these the technic may not only be more 
easily acquired but more easily and rapidly applied, and with a 
smaller margin of error than when regional anesthesia is attempted. 

In the excellent monograph upon regional anesthesia by Sherwood- 
Dunn (page 168), in which he describes the A ictor Pauchet technic, 
which may be said to reflect to some extent the present status of the 
situation in France, the comment is made that in order to secure 
complete anesthetization for pelvic surgery it is necessary to block the 
6 lower thoracic, 3 lumbar and 3 sacral nerves on each side. This 
w ould actually mean a blocking of 24 separate nerves in order to 
secure complete anesthesia. It is small wonder that the same 


author concludes that local anesthesia is not satisfactory for pelvic 
surgery and states that they prefer intraspinal anesthesia and use 
it as a routine procedure. 

If those who are to be considered experts in the use of local 
anesthesia give the surgical profession the impression that it is 
necessary to master and use this complicated technic in order to do 
abdominal surgery, it may be taken as a foregone conclusion that 
the method will not be accepted by any but a few specially trained 
experts who are enthusiastic enough to perfect themselves in its use. 
If, on the other hand, surgeons can be made to realize that a proper 
infiltration of theabdominal wall, together with splanchnic anesthesia, 
will enable one to perform many, and indeed most of the abdominal 
operations, that this infiltration can be learned with comparative 
ease, and that with proper equipment analgesia can be established 
in from three to five minutes, and that the operation may then be 
begun at once, the prospect of obtaining its adoption will be greatly 
enhanced. The main difficulty seems to lie in convincing surgeons, 
and even expert local anesthetists, that a procedure so simple will 
give the desired results. As a matter of fact, infiltration anesthesia 
may be said to be almost ideal for the simple pelvic operations, such 
as the removal of an appendix, suspension of the uterus, and the 
removal of small fibroids or ovarian cysts. Even in the presence 
of adhesions and complicated pathology, many of the conditions 
may be met with a great deal of satisfaction, provided the proper 
strategy is employed. With the addition of sacral anesthesia, the 
induction of which is much more simple than the induction of 
anesthesia by the paravertebral method mentioned above, pelvic 
work of any character may be performed under local anesthesia. 

Considering the relative merits of direct infiltration and para¬ 
vertebral block, for instance, it might be well to refer to the follow- 


142 


GENERAL TECHNIC 


ing comments made by Prof. Braun concerning paravertebral 
anesthesia i 1 

To anesthetize the larger part of the abdominal cavity by para¬ 
vertebral anesthesia requires the blocking of a considerable number 
of segments. Kappis reports that the intestine is supplied bilater¬ 
ally in its entire course, and thus an operation on but one side of the 
abdominal cavity calls for bilateral blocking. Pelvic operations 
require in addition blocking of the sacral plexus and Reinhard and 
Siegel combine paravertebral with parasacral anesthesia. Reports 
of (1) abdominal laparotomy show that 22 skin punctures and 330 
cc of 0.5 per cent solution are required; (2) pelvic laparotomy, 
20 punctures and 400 cc; (3) vaginal, uterine and adnexa operation, 
10 punctures and 400 cc, which were all bilateral; and a nephrectomy 
with 12 unilateral punctures and 240 cc. Braun and Kappis did 
not get anesthesia of the appendix with unilateral paravertebral 
injections, but only anesthesia of the abdominal wall and parietal 
peritoneum, and to get the desired anesthesia, Braun suggests a 
much simpler method. A unilateral paravertebral block in the 
kidney operation likewise does not produce complete anesthesia of 
the pedicle. 

On the other hand Jurasz did 2 cholecystectomies (complicated) 
with but a unilateral block. 

Aside from the above features, the technic of paravertebral 
blocking is not easy for the beginner, which is the case with any 
technical procedure. 

Under no circumstances must the needle be allowed to approach 
too near the intervertebral spaces. Wilms, Franke and Kappis 
noted severe collapses following paravertebral injections, which 
they explained by novocain entering the spinal canal. 

Muroya, in previous experiments, had shown that novocain is 
more toxic in paravertebral administration than when injected 
subcutaneously. Close adherence to the technic of the various 
authors should avoid puncturing the intervertebral spaces them¬ 
selves, especially if one does as Siegel does—that is, make the 
point of initial injection a considerable distance from the midline. 
Jurasz also is right when he says that it is not necessary to blame 
the bad effects to entrance of novocain into the spinal canal, but 
that the total dose of novocain used is too great. When one 
considers that Kappis uses as much as 3.3 gm. of novocain in 1.5 
per cent solution and Siegel 2.3 gm. in 0.5 per cent solution, one 
must consider this argument. It must be admitted that the 
weaker solution of Siegel is the more commendable in warding off 
bad effects. 


* Braun, H,: Local Anesthesia, 5th edition, 1919, p. 334, 


METHODS OF ADMINISTERING LOCAL ANESTHESIA 143 


Because of the numerous injections (20 to 22) required in para¬ 
vertebral anesthesia, the patience of both surgeon and patient is 
heavily tried. Braun agrees with Hartel in spite of the recom¬ 
mendations of Reinhard and Siegel, that the question of regional 
anesthesia in abdominal operations, by means of paravertebral 
injections, has not yet been satisfactorily solved. 

Thus it is interesting to note that this master in the use of local 
anesthesia is not wedded entirely to the regional method, as he 
states that simple infiltration suffices for many varieties of abdomi¬ 
nal operations. His realization that, through strategy, the avoid¬ 
ance of traction, the abolition of reflexes, and so forth, one is per¬ 
mitted to carry out these procedures is apparent. 

When one considers the amount of solution used and the extensive 
and complicated technic required for carrying out a paravertebral 
block it is not to be wondered at that a man with the experience and 
judgment of Braun is somewhat dubious concerning the advantages 
of the paravertebral method. 

In the experience of the author it is unusual to spend more than 
five minutes in inducing anesthesia by the direct infiltration method. 
Furthermore, it is unusual to use more than 200 cc of solution in 
order to obtain anesthesia of the abdominal wall. Even to the 
expert, direct infiltration presents advantages which cannot be 
gainsaid, and to the novice the development of knowledge concern¬ 
ing the technic of paravertebral block seems an insurmountable 
obstacle. The end-result may be said to be an inhibitory influence 
upon the surgeon who otherwise might gradually develop ability 
to employ local anesthesia. 

THE CHOICE OF METHODS OF ADMINISTERING 

LOCAL ANESTHESIA. 

The choice of methods is influenced by a variety of factors. 
lntras'pinal anesthesia, which is the ultimate refinement of the 
conduction or regional method, has not been used to any extent by 
the author on account of his belief that in the hands of any but the 
most expert this form of anesthesia subjects a patient to unnecessary 
hazard. While it is his belief and hope that ere long methods will 
be developed whereby the average surgeon may use intraspinal 
anesthesia with safety, his impression is that at the present time 
too many lives will be lost by a surgeon while developing a knowledge 
of the technic to justify its use as a routine measure by the average 
surgeon. 

An argument often brought forward in the presentation of the 
merits of regional anesthesia is that this method requires the use of 
less solution than docs the infiltration method, with attending 


144 


GENERAL TECHNIC 


decrease in danger from absorption. It is questionable whether 
the alleged advantage is a great one, as some of the solution used in 
infiltration anesthesia escapes through the incision which is made 
directly through the edematous area, while all the solution used in 
regional anesthesia remains to be absorbed. While the author 
does not believe that its absorption has a very deleterious effect 
upon the economy of the patient, the point must be recognized in 
forming judgment upon the relative merits of the two methods— 
regional versus infiltration anesthesia. As a matter of fact the 
reports from the clinics of those who use paravertebral anesthesia 
fail to convince one that the regional method, in abdominal work 
at least, is to anv extent a conserver of the anesthetic solution. 

On account of its flaws, the author feels that regional anesthesia 
meets in direct infiltration a competitor with so many points of 
excellence that, in many instances, the “ideal'’ may well be replaced 
by this more practical method. Direct infiltration possesses the 
obvious advantages of speed, simplicity, wide application, and the 
important attribute that the technic may be acquired and accom¬ 
plished with comparative ease. True, in the hands of the expert, 
regional anesthesia is efficient in certain areas, and the more expert 
one becomes, the more perhaps may he depend upon this form of 
anesthesia. 


It is believed, however, that for routine abdominal work where 
direct infiltration is not contraindicated it will more and more 
become the method of choice in the hands of the average surgeon. 
The conclusions of Braun, arrived at only after rich experience, 
are very significant. The conviction holds that direct infiltration, 
which is extremely simple provided the proper equipment, strategy 
and a refined surgical technic be used, will make infiltration anes¬ 
thesia a worthy competitor of the paravertebral method. 

Infiltration Anesthesia Technic.— As stated above a most impor¬ 
tant factor is the actual manner of introducing the anesthetic solution. 
If one bears in mind that the introduction of the anesthetic comes at 
a time when the apprehension of the patient is the greatest, when 
the method, so to speak, is more or less on trial and when every 
painful sensation is apt to be magnified by the apprehensive patient, 
it is perfectly obvious that at this stage of the procedure actual 
discomfort must be reduced to a minimum. Here the nerve block 
or regional anesthesia is less reassuring than is infiltration anesthesia. 
By the observance of the rules laid down later on in this chapter, 
(page 149) it is possible to make a complete infiltration of a given 
field almost without any painful sensation, except in the production 
of the first wheal, provided the injection is made at the proper 
cadence and the necessary precautions are taken. 

From the standpoint of the ysychic element alone it would seem 


METHODS OF ADMINISTERING LOCAL ANESTHESIA 145 


expedient to simplify as much as possible the methods of producing 
local anesthesia. 1 he equipment, technic and manner of handling 
the patient, the esprit de corps of the operating force, all play a part 
in reducing that disturbing element known as “ psychic incom¬ 
patibility. In using infiltration anesthesia one may make use of 
the advantages to be derived from the non-necessity of changing 
the patient’s position and preparation of two fields. The psychic 
disturbances are not nearly so marked in cases in which the patient 
may be placed comfortably upon the operating table and allowed 
to remain without change of position while the anesthesia is being 
given and the operation proceeds. It is not an uncommon practice 
with the author to “slip over” the operation upon the conscious 
patient without his knowledge of the fact that he is being operated 
upon. The psycho-anesthetist gives the patient the impression that 
he is being prepared and many times an operation may be com¬ 
pleted, or nearly completed, before the patient realizes that it is 
actually in progress. In using regional anesthesia no such oppor¬ 
tunity is offered. 

In a recent monograph on the subject of local anesthesia the 
statement is made that the infiltration of the skin from beneath is a 
painful procedure—if anything, more painful than the production 
of intradermal wheals when these are made in the usual manner 
from without. On the contrary experience demonstrates that 
intradermal wheals may he made from beneath without the slightest 
sensation of pain. A realization of this fact and the application of 
the principle involved is the most important factor in the painless 
introduction of local anesthesia solutions. By making all secondary 
wheals from beneath, as shown in Fig. 31, page 149, the painful sen¬ 
sations produced by the needle are at once eliminated. In a lipec- 
tomy, for instance, it may be necessary even though a 10 cm. needle is 
used to puncture the skin at ten or a dozen different points in order 
to sufficiently anesthetize the field. The average individual will 
not lie and complacently submit to this procedure without at least 
reflecting upon the assurance that he had been given, that the 
operation would be painless. The illustrations in works on local 
anesthesia show, in some instances, six or even eight points at which 
intradermal wheals are made in the unanesthetized skin. Only 
the most stoical and phlegmatic, or those deeply narcotized by 
preliminary hypodermics, will submit to this procedure without 
offering complaints. 

During a visit to a clinic of a most excellent surgeon the author 
saw this point well illustrated. The patient, a splendid candidate, 
was prepared for the hernia operation. As a preliminary, four 
points were marked upon the skin, outlining the proposed area to 
be injected. The marking was done with a needle, a little cross 

10 


146 


GENERAL TECHNIC 


being made upon the skin at each point. This procedure was not 
especially painful. However, the patient, although not particu¬ 
larly apprehensive, complained, the vociferousness of his complaint 
being in exact ratio to the number of crosses made. That is, the 
complaint elicited by the making of the fourth cross was approxi¬ 
mately four times as vigorous as the one following the making of the 
first. The next step consisted in making an intradermal wheal 
at each of the designated points. The production of the first wheal 
was accomplished by a still more vigorous complaint, the patient 
moving about somewhat on the table and the surgeon manifesting 
some embarrassment, the fact being apparent that both of these 
individuals were beginning to lose their self-control. After some 
argument the second wheal was attempted but the patient refused to 
permit further wheals to be made. The surgeon then called for 
general anesthesia and the operation was performed under its 
influence. 

One must bear in mind that the introduction of a hypodermic 
needle through the skin is accompanied by exactly the same amount 
of pain as is the introduction of a sewing needle through the skin, 
and, while no one will object greatly to this procedure being carried 
out once, its repeated performance will seldom be tolerated. Even 
where regional anesthesia is employed, the intradermal wheals 
should be made from beneath, as illustrated on page 149, Fig. 31, 
so that the needle punctures necessary for reaching the separate 
nerves will be entirely painless. In the chapter on Abdominal 
Surgery this subject is considered somewhat more in detail. 

The comparative harmlessness of novocain, if used in weak 
solution, 0.5 to 1 per cent, and properly retained in the tissues by 
the use of adrenalin or the tourniquet, has given a great impetus to 
the infiltration method. In addition, the complete establishment 
of anesthesia before beginning the operation has also made this 
method extremely practical and satisfactory. 

And, finally, the development of the Pneumatic Injector (see 
Fig. 5, page 89) has made the induction of the anesthetic so 
simple, easy, accurate and rapid that the former complications, 
difficulties, errors and partial failures have, in the author’s clinic, 
almost entirely disappeared. A certain established routine technic 
for a definite region, or for the performance of a certain operation, 
will result in a definite, fixed response on the part of the tissues with 
almost no margin of error. There need be little guesswork about 
this matter. The margin of safety is sufficient so that the surgeon 
may establish anesthesia in every case. Other things being equal, 
a certain area will demand a definite amount of the solution, and 
this amount need only be increased in case the mental attitude of 
the patient is such that any error might lead to trouble with this 


SOME CAUSES OF FAILURE OF LOCAL ANESTHESIA 147 

particular patient. Provided the solution is deposited in the tissues 
\\ hich hi e know n to require it there will be but slight danger in using 
a sufficient amount to insure anesthesia. 


SOME OF THE CAUSES OF FAILURE OF LOCAL ANESTHESIA 
IN ABDOMINAL SURGERY. NEGATIVE PRESSURE.* 

What are the usual causes of failure to obtain a satisfactory 
working condition when the abdomen has been opened under local 
anesthesia? Surgeons have frequently said to the writer when 
discussing this subject, “I can open the abdomen without any 
complaint on the part of my patient, but as soon as the abdomen is 
opened the intestinal coils present themselves in the incision and, 
unless forcibly restrained, protrude through the wound.” When 
this occurs the intestines must be forcibly restrained by means of 
gauze pads and this restraint will be responded to by the patient 
and by his abdominal muscles in no uncertain manner. Forcible 
restraint of the abdominal viscera under pressure will almost 
invariably cause a reflex expulsive effort, which will only serve 
further to increase the intra-abdominal pressure. Thus a vicious 
circle, so called, has been established; the increased pressure upon 
the viscera produces an increase in the expulsive effort which, 
in turn, demands a further increase in pressure. When this condi¬ 
tion presents itself it will usually be necessary to administer general 
anesthesia and complete the operation under its use. 

Though such a condition may be present occasionally when using 
local anesthesia under the best of auspices, it should not, as a rule, 
be met w T ith and its occurrence is almost alw ays a direct evidence of 
inefficiency in the manner of inducing local anesthesia or in the type 
of surgical technic employed. 

Experience during recent years has shown that it is not only 
entirely possible to avoid the positive intra-abdominal pressure 
when the abdomen is opened, but to find in its stead what is termed 
“negative pressure.” While there are exceptions to this rule, 
notably in acute abdominal conditions in which marked distention 
is present or in individuals with chronic recurring types of trouble 
who develop extreme sensitiveness of the intraperitoneal organs 
and tissues, it is safe to say that the “ negative pressure,” so called, 
can usually be obtained. Even in the presence of peritonitis with 
distention a perfect anesthesia of the abdominal wall, combined with 
the proper technic when making the incision, will usually present a 
condition of quiescence of the viscera and, even though the organs 
do not fall away from the abdominal wall, there will be no effort 

* Referred to in an article read before the section on Obstetrics, Gynecology and 
Abdominal Surgery at the Sixty-eighth Annual Session of the American Medical 
Association, June, 1917, and in Journal-Lancet June 1, 1917. 


148 


GENERAL TECHNIC 


at protrusion. Under these conditions one may by the use of 
vertical retraction and the careful application of gauze pads carry 
out rather extensive procedures upon even acute cases. While 
it is realized that there are certain individuals and types in which 
this negative pressure cannot be obtained, just as there are types 
of cases and individuals that are incompatible with the use of local 
anesthesia, the cause of failure lies usually with the surgeon, rather 
than with the patient. 


GENERAL CONSIDERATIONS REGARDING THE INDUCTION OF 
LOCAL ANESTHESIA AFTER THE TIME HAS ARRIVED 
FOR THE GIVING OF THE ANESTHETIC. 

Perhaps the most important period to be bridged while carrying 
a patient through the ordeal of a surgical operation under local 
anesthesia is that during which the anesthesia is actually being 
introduced. The success or failure of the procedure is dependent 
to such a large extent upon the deportment of the surgeon during 
these few minutes that one may predict on the one hand a smooth, 
efficient anesthesia with a successful operation upon a contented 
patient, or on the other a disgruntled, irritated or apprehensive 
patient, whose confidence has been lost at the very beginning, and 
upon whom a successful operation cannot be carried out because of 
technical errors which have crept in. 

As a rule the condition described is due to the fact that the 
patient has been subjected to pain during the infiltration and 
making of the incision, notwithstanding the fact that he may not 
have complained. Surgeons differ very materially in their estimate 
of this factor. Some call a procedure “painless” when a patient is 
continually flinching and making grimaces in direct consonance with 
each painful maneuver on the part of the surgeon, or even when 
mild restraint is necessary. Others call a procedure “painless” 
when they have been repeatedly called upon to reinforce the anes¬ 
thesia, while some even consider a procedure “painless” when the 
patient is fervently grasping some friendly bystander by the hand 
and hanging on for dear life. 

In the introduction of the solution certain fundamental principles 
must be followed in order to insure success, no matter whether 
regional or infiltration anesthesia is used. 

The less the delay after the patient enters the operating room and 
the smoother the action of the operating room force in making the 
preparation, the better w ill be the mental condition of the patient 
and the lighter will be the tax put upon the surgeon in carrying out 
the operative procedure. The surgeon’s confidence and in fact 
the confidence of his staff of helpers will be vividly reflected in the 
patient’s demeanor. 


THE INTRODUCTION OF THE ANESTHETIC SOLUTION 149 


THE INTRODUCTION OF THE ANESTHETIC SOLUTION. 

Technic.— The Initial Wheal (Fig. 31, A ).—When introducing the 
solution the development of the initial wheal is accompanied by 
certain preliminaries which are designed to relieve the tension under 
w hich the patient may be laboring. These preliminaries vary, 
depending upon the circumstances, but usually consist of a slight 
sponging, pinching or patting of the skin over the field of operation. 
As the first needle prick is about to be made the psycho-anesthetist 
cautions the patient, stating that the doctor is about to administer 
a hypodermic. At the same time the surgeon may request the 
patient not to move when he feels the needle-prick. When these 



Fig. 31.—Painless method of inducing anesthesia. A, initial wheal; B, secondary 
intradermal wheal made from beneath (painless); C, subdermal infiltration with 
needle receding. 


precautionary measures are omitted the unprepared patient is 
surprised; his confidence, which already may be more or less nega¬ 
tive in quantity, is apt to be shaken and a slight movement on his 
part is apt to result in dislodging the needle point, thus making 
it necessary to repeat the procedure. Each detail alone, though of 
apparently minor importance, assumes great significance when all 
of the small errors in technic are considered in the aggregate and it 
is the cumulative effect of a series of minor “overt acts” which is 
most often the cause of failure in carrying out an operation under the 
use of local anesthesia. 

Anesthetization of the Skin Line.— Intradermal Method.— The skin 
may be anesthetized by means of either an intradermal or sub- 




















150 


GENERAL TECHNIC 


dermal infiltration. The method of making the intradermal 
injection is as follows: 

The needle point is introduced beneath the superficial layers 
of the skin and the solution is deposited directly into the layers of 
which the skin is composed, a skin wheal being made. The needle 
is then withdrawn, reintroduced near the edge of this initial wheal, 
and an adjacent area of skin is edematized. This process is con¬ 
tinued to any extent desired. This method results in the estab¬ 
lishment of immediate anesthesia, the main objection to its use 
being its irksomeness and the necessary loss of time when using it. 
We have replaced this method of anesthetizing the skin by the 
subdermal method, except in the anesthetization of the points upon 
the skin through which the needle must be inserted (Fig. 31, B and 
C, page 149). 

The Author s Subdermal Method.— The production of subdermal 
anesthesia is brought about by the introduction of the needle 
through an intradermal skin wheal and advancing it beneath and 
parallel to the skin, the solution being deposited directly beneath 
the skin layer, either while the needle is advancing or receding 
(Fig. 31, C, page 149). The subdermal infiltration, if made in close 
proximity to the internal layer of the skin, will produce anesthesia 
in a period of from one to three minutes. The employment of a 
subdermal infiltration has the advantage of speed and ease of 
execution, as the tissues through which the needle passes are non- 
resistant to both the needle and the injected fluid. By the use of 
this method an area of approximately the length of the needle may 
be almost instantly anesthetized with one stroke. 

The Painless Secondary Intradermal Wheal.— This method has an 
additional advantage, which is of prime importance in the introduc¬ 
tion of local anesthetic solutions. By its use one is enabled to 
develop secondary intradermal wheals (Fig. 31, B, page 149) from 
beneath without the production of pain. One may therefore, by 
making use of the subdermal infiltration for anesthetizing the skin 
and the subdermal route for the production of secondary wheals, 
greatly reduce the irksomeness and the time required for anesthe¬ 
tizing a given area and —a most important consideration —one may 
by following out this plan avoid the necessity of repeatedly pricking 
the unanesthetized skin of the patient. 

Lifter making the initial wheal one important point is to be kept 
constantly in mind —the patient is to feel no more needle pricks 
throughout the procedure of making the infiltration. It matters not 
at how many points the skin is to be pierced by the needle, the 
unanesthetized skin must not be pierced. This may be avoided by the 
use of the following technic: The long needle is introduced through 
the initial wheal and advanced beneath and parallel to the skin 


THE INTRODUCTION OF THE ANESTHETIC SOLUTION 151 


surface in the subdermal fat to a point within 2 to 3 cm. of its hilt. 
Just in advance of the needle point the skin surface is made to 
curve inward by making pressure upon it with the finger (see Fig. 
31, B), or by the use of a flexible needle the point may be made to 
travel upward and engage in the skin. This is done by elevating 
the base of the needle as it advances, thus curving the needle. 

This painless method of anesthetizing the skin is the most 
important single jactor in the technic of the administration of local 
anesthesia, and careful attention to the execution of its minutest 
detail will do much to facilitate the work. On the other hand when 
following the usual technic, or that usually seen at least where the 
patient is repeatedly pricked in an unanesthetized area, we must 
expect even the most stoical to ask for an interpretation of the term 
“painless.” Even where the intradermal wheals are continued from 
the initial wheal and the skin infiltration for any distance, too rapid 
injection will cause pain. Besides, this process is slow, laborious 
and unnecessary. The subdermal infiltration will be found to give 
complete anesthesia in from two to four minutes and, as the deeper 
layers should be anesthetized before the incision is begun, this 
amount of time is sure to elapse before the incision can be made. 

The Technic of Deep Layer Infiltration.—After the outline has 
been made upon the skin by the more or less regularly placed wheals 
and the line of subdermal infiltration is made, the deeper layers are 
anesthetized before making the skin incision. There are many 
reasons why the method of injecting the tissues layer by layer while 
incising should be discarded, at least as a routine procedure. The 
delay occasioned by its use is in itself a sufficient reason to condemn 
it, especially as the complete infiltration is so satisfactory. It is 
felt, however, that the main objection to it is based upon the 
greater likelihood of the production of pain when this plan is 
followed. The immediate infiltration of the deeper layers gives the 
anesthetic time in which to act upon these tissues while the pre¬ 
liminary incision is being made, vessels secured and towels applied 
to the skin. Except in very fat persons one may quite accurately 
recognize the different layers as they are reached by the needle point 
and the required amount of solution may then be deposited. An 
approximate estimate of the thickness of the different layers, as well 
as a knowledge of the relative sensitiveness of the various tissues to 
be injected, is essential. Any errors as to the thickness of the 
different layers are to be checked by the impression made upon the 
patient as sensitive areas are encountered. In the abdominal wall, 
for instance, after the subdermal infiltration is made, the next 
layer of interest to be encountered is the aponeurosis. This layer 
can be recognized by its “ feel” and by the fact that the patient will 
manifest signs of discomfort when it is reached, though if care is 


152 


GENERAL TECHNIC 


used this discomfort is slight. The anesthetist can usually catch 
the change of expression on the part of the patient, but a more 
desirable guide is the slight muscular contraction which invariably 
accompanies any appreciable insult to sensitive tissues. Once the 
approximate depth of this layer is estimated the fluid is deposited 
in sufficient quantity to produce anesthesia ahead of and about the 
needle point for some distance, thus making further punctures 
possible without the patient or the local part realizing that it is 
being done. A perfect knowledge of the anatomy of the region 
allows one to make the injection without any complaint on the part 
of the patient, and with only slight muscular protest. Of course, 
one must regulate the speed and amount of anesthetic used in a 
given area by the sensitiveness of the tissues, a condition dependent 
upon the location of the area attacked, as well as upon the make-up 
of the individual patient. For instance, one patient may allow the 
complete blocking for an appendectomy in two minutes without the 
slightest local or general protest, while in another patient of about 
the same dimensions five minutes may be required for the same 
procedure. The deep layers of muscles in the abdominal wall, 
while containing some sensory nerves, are relatively devoid of sensa¬ 
tion and need very little of the anesthetic. But, as there is little 
objection to the use of the solution here, it is better to play safe and 
to continue the injection as the needle advances toward the pre- 
peritoneal fat, which is the most sensitive tissue beneath the skin. 
This tissue is therefore approached and entered with a constant 
stream flowing from the needle. As soon as the slightest sign is 
manifested by the patient, or even if no signs, local or general, are 
shown, the area about the point of the needle is “soaked,” the 
needle withdrawn and new fields attacked by a repetition of the 
procedure. The same precautions should be used by the surgeon 
when he is about to enter an area which may be sensitive, as when 
the first wheal is made. It is usually well to say, “ Let me know 
whether you feel this,” or “Is this sensitive?” 

Safety of Deep Infiltration.—There seems to be much timidity on 
the part of surgeons regarding the making of deep infiltrations into 
the abdominal wall. The dangers from this procedure are more 
apparent than real, and experience shows that they are practically 
nil . The author has repeatedly advanced the needle through the 
abdominal wall with the abdomen open and the fluid flowing from 
the needle in order to learn what takes place when this maneuver is 
carried out. Colored solutions have sometimes been used for this 
purpose. It has been found that, provided the needle is slowly 
advanced, the preperitoneal tissue becomes swollen from the out¬ 
flowing fluid and the peritoneum generally floats away from the 
needle point and is not subject to puncture, provided the needle is 


THE INTRODUCTION OF THE ANESTHETIC SOLUTION 153 

not advanced rapidly (F ig. 211, page 490). The peritoneum may be 
punctured, reproducing the condition we have in the intraperitoneal 
injections of guinea-pigs and other animals in which, as is well 
know n, intestinal injury does not occur. This fact is now estab¬ 
lished bc\ ond question and should have a marked influence in 
simplifying the technic. 

In the case of visceroparietal adhesions the needle may be intro¬ 
duced either through the incised abdominal wall, that is, extra- 
peritoneally or upon the visceral side of the “white line,” in order 
to bring about an infiltration of the visceroparietal junction. This 
maneuver will allow one to painlessly introduce the solution where 
it is required. 

While carefully carrying out the above methods in the minutest 
detail the field of infiltration is gone over methodically and sys¬ 
tematically with the object of not missing a fraction of a cubic 
centimeter. 

It is here that the use of the Pneumatic Injector (see Fig. 5, 
page 89) assumes a special role of superiority over the syringe. The 
constant source of supply of the solution relieves the operator of the 
necessity of filling or changing syringes, a maneuver which is prone 
to make the surgeon "lose his place” and to miss a small area, which 
may correspond to the location of a sensory nerve. Again, the 
lightness and adaptability of the cut-off allows one to develop an 
ability to "feel” the location of the needle point and to introduce 
and direct the needle with the greatest ease. The greatest advan¬ 
tage, however, is the elimination of " muscle tire,” as the fluid is 
injected by the simple "tripping” of the thumb-piece of the cut-off, 
the hand never out of position and but slight muscular effort required. 

Once the sensitive tissues are thoroughly edematized anesthesia 
should be complete almost immediately, or at least before the 
various layers are reached by the scalpel. The skin may be incised 
directly after the deep injection is completed, and a secondary 
cleansing with iodin, alcohol or some other solution, is made. 

Technic of Skin Incision and Opening of the Abdominal Wall (See 
Fig. 212, page 490).—In making the incision in abdominal cases it is 
well to avoid making pressure upon the abdominal wall. Even 
with a perfect anesthetization the pressure produced by the use of 
a dull scalpel, especially in unskilled hands, will cause the patient 
discomfort even in the "interval” case, while in cases of acute or 
subacute infection pressure will not be tolerated. In order to meet 
this contingency the skin should be elevated between two pairs of 
towel clips while the incision is being made (Fig. 212, page 490). 
A sharp scalpel is used and multiple gliding strokes are made rather 
than a forceful pressure of the blade through the tissues. The delay 
necessitated by the placing of towels for skin exclusion allows the 


154 


GENERAL TECHNIC 


deep tissues sufficient time in which to become anesthetized and the 
incision is carefully carried down through the succeeding layers, 
care being taken not to slacken for an instant the vigilance regarding 
the elevation of the abdominal wall until the peritoneum is finally 
opened. 

SURGICAL TECHNIC AND SOME OF THE ADJUNCTS 
DEMANDED BY LOCAL ANESTHESIA. 

The no-hand-touch and feather-edge dissection which mark such 
an improvement in the newer surgical technic is most compatible 
with the use of local anesthesia; indeed, those most expert in the 
use of local anesthesia must be credited, to some extent, at least, 
with abetting the aforementioned improvement in the technic of 
general surgery. It is safe perhaps to say that as a universal proposi¬ 
tion the demands of local anesthesia and the patient’s best interests 
are in this regard more or less identical. 

Sponging.— The simple procedure of sponging bleeding surfaces 
is much abused. As a rule, the small vessels will cease to bleed 
almost instantly through the formation of a clot in their severed 
ends, provided the clot is not forcibly removed by sponging. The 
average abdominal incision may be made almost without the use 
of artery forceps if this principle is recognized. Rough sponging 
will prevent Nature’s styptic action and cause the bleeding to 
continue. In the author’s clinic suction has been used largely to 
replace the use of sponges. A universal use of this principle will 
serve greatly to reduce the amount of oozing and will insure a 
better visualization of the field of operation. One must be exceed¬ 
ingly careful in the manner of sponging when doing abdominal work 
under local anesthesia. This point is frequently illustrated. 
Each new assistant must be repeatedly cautioned regarding it. 
As a rule, the less experience this individual has the more easily 
he will be trained to respect the tissues when sponging. The 
assistant who has had considerable experience in general surgery 
under inhalation anesthesia is almost always the worst offender, 
not only in regard to sponging, but in his manner of retracting 
wounds, applying artery forceps and in many other ways. One 
of the simplest ways of drying the field, especially in deep cavities 
in the abdomen, is by suction. This method causes less trauma and 
is more efficient than any other. It is deserving of more universal 
adoption. 

Tying of Ligatures.— The method of tying ligatures, while 
perhaps not of great importance, might be mentioned as a good 
indication of the respect a surgeon may develop for the tissues. 


SURGICAL TECHNIC DEMANDED 


BY LOCAL ANESTHESIA 


155 


The drawing of ligatures back and forth through the gloved hand 
is not conducive to the carrying out of an aseptic technic, and 
while tying ligatures with the hands may be done deftly and satis- 


B 






Fig. 32.—The forceps tie of Grant. A, B, C and D, tying first knot. 

factorily on the surface of a wound, the carrying out of this procedure 
in deep cavities where the space is somewhat limited is almost sure 
to result in traction. The forceps tie, described by Grant, is so 




156 


GENERAL TECHNIC 


easily learned and so well fulfils the requirements that it is to be 
recommended in local anesthesia work. We have amplified the 
technic of the forceps tie, as shown in Figs. 32, 33, and 34, and have 
described them as the three-forceps and four-forceps method. 

The following description is reprinted from Surgery, Gynecology 
and Obstetrics: 1 


The Three-forceps and Four-forceps Knot.—In the tying of liga¬ 
tures during a surgical operation, it is desirable to use methods 
which conserve ligature material, eliminate handling of the ligatures 
by the gloved hands, facilitate tying in deep, narrow cavities, and 
possess the attribute of speed. The forceps tie described by Grant 
in Surgery, Gynecology and Obstetrics, May, 1918, page 559, possesses 
these attributes to a greater degree than does any other method. 
The method of Grant is shown in Fig. 32, A, B, C and D. To 
complete the knot the forceps in the operator’s right hand, B, is 
placed beneath the ligature instead of above it. 

The methods devised by the author, namely, the “three-forceps” 
tie and the “four-forceps” tie, are illustrated in Figs. 33 and 34, 
A, B, C and D, and are simply an amplification of the method of 
Grant. 

The Three-forceps Tie.—The “three-forceps” tie utilizes the 
assistant’s hand, one of which is usually free. The technic is as 
follows: 

After the first portion of the Grant knot is tied the assistant 
presents the forceps (Fig. 33, A), preferably with the point directed 
toward the operator’s face. The operator then loops the ligature 
about the assistant’s forceps (Fig. 33, B) and “feeds” the short end 
of the ligature to the assistant (Fig. 33, C). The assistant then 
simply makes taut the short end (Fig. 33, D) while the operator 
draws the ligature over the end of the assistant’s forceps and forces 
the knot home. In working in deep cavities the operator may 
assist in completing the knot by making pressure upon the short 
end of the ligature with the needle holder, which he holds in his 
right hand (Fig. 33, D). 

The Four-forceps Tie.—The “four-forceps” tie is simply a duplica¬ 
tion of the Grant knot, except that while the operator is tying the 
first portion of the knot the assistant prepares for the second step 
(Fig. 34, A). By the time the operator has completed the first half 
of the knot (Fig. 34, B) the assistant is ready to grasp the short end 
and complete the knot (Fig. 34, C). In case it is thought advisable 
to lock any of these knots a second revolution of the ligature may be 
made about the forceps. 

The Gauze Retractor (Fig. 35).—One of the most simple methods 
of grasping the kidney, the distended gall-bladder, an ovarian cyst 


1 Farr, Robert Emmett: The Three-forceps and Four-forceps Knot, Surg., Gynec. 
and Obst., October, 1920, pp. 408, 409. 


SURGICAL TECHNIC DEMANDED BY 


LOCAL ANESTHESIA 


157 



O.LH. 



Fig. 33.—Author’s three-forceps tie utilizing assistant’s forceps in completing forceps 

tie of Grant, 













158 


GENERAL TECHNIC 


or any tumor mass which cannot be readily grasped by any of the 
ordinary grasping instruments is to employ a strip of gauze for this 
purpose. Figs. 35, page 159, and 131, page 445, will illustrate the use 
of gauze as a retractor. We have found the gauze retractor especially 
efficient in elevating the gall-bladder and kidney. The gall-bladder, 



Assistants left hand 



A.R.H. 



Fig. 34.—Author’s four-forceps tie. While operator completes first portion of knot, 
the assistant prepares A to complete the knot B and C. 


which is acutely distended, may be manipulated by means of the 
gauze retractor without the danger of rupturing and spilling its 
contents. The same is true of kidneys that are distended with 
septic material. The placing of the gauze tractor upon the dis¬ 
tended gall-bladder is extremely simple. The ends of a folded strip 
of gauze are grasped in one hand while the center is fixed by a long 













SURGICAL TECHNIC DEMANDED BY LOCAL ANESTHESIA 159 



in this position the surgeon simply twists the ends until the gauze 
fits snugly about the gall-bladder. A second hemostat may then 
be placed upon the gauze in close proximity to the gall-bladder, 
thus fixing the tractor in place. In placing the tractor upon the 
partially mobilized kidney more strategy is required. The gauze 
is held as described above and as soon as one pole of the kidney has 
been freed the center of the loop of gauze is carried between the 
kidney pole and the pedicle by means of long curved forceps. The 
adjacent portions of the gauze strip are forced deeply into the 
wound and allowed to remain until the opposite pole of the kidney 
is freed to a degree that will allow the tractor to surround the 
kidney along a line between its pedicle and the meridian. One 
has now but to cross the ends of the gauze over each other, place 
forceps upon them and twist the two ends together until the pedicle 
only remains grasped in the loop of the gauze. 



Fig. 35.—Gauze gall-bladder retractor. 


Operating Room Deportment.— The average patient enters the 
operating room with an attitude of more or less anxiet\ and appie- 
hension, with which may be mingled elements of fear, loneliness 
and often actual distrust. Even when none of these elements is 
manifest one or more of them are undoubtedly present, at least in 
the subconscious mind. Nothing will serve to crystallize these 
mental processes more effectually than the failure on the pait of the 
operating room force to function smoothly. 1 he question of com¬ 
fort, quiet and the avoidance of irritations, combined with proper 
deportment, will go far toward reassuring the patient. In this 
connection it is believed that perhaps one of the most important 
items is the manner in which the anesthesia is actually induce< . 
A patient is much more perturbed when sacral anesthesia is inducec 
and his position on the operating table has to be changed before the 
operation is begun than when a comfortable position is assumed 



160 


GENERAL TECHNIC 


before the anesthetic is given and no change is made in the patient’s 
position between the giving of the anesthetic and the performance 
of the operation. 

The Psycho-anesthetist.— While it is perfectly true that certain 
operations may be carried out with a small margin of error under 
local anesthesia, it is also true that for the present at least a con¬ 
siderable percentage of operations will demand the use of general 
anesthesia. A surgeon who essays to do a portion of his surgery 
under the influence of local anesthesia must therefore be equipped 
so that he may offer his patient mixed or general anesthesias as the 
occasion requires. In order to do this he must have associated 
with him someone who is especially trained for this work. The 
presence of such an individual is fully as necessary when local 
anesthesia is to be used as when inhalation anesthesia must be 
given. The fact that anesthesia by inhalation may become neces¬ 
sary during the performance of almost any operation under local 
anesthesia makes the presence of an anesthetist more or less impera¬ 
tive. The author has proposed the term “psycho-anesthetist” 
for this individual, the first word of the term referring especially 
to the duties which the anesthetist is called upon to perform when 
local anesthesia alone is being used, and the second signifying the 
duty of this individual when general anesthesia is used. This 
individual should by preference be a woman, and a tactful trained 
nurse is usually employed for this purpose. The attributes of 
loyalty, enthusiasm and tact, a combination of which is so desirable, 
are found most available in the trained nurse. She should be 
thoroughly instructed and should have considerable experience 
in the administration of general anesthesia. She may then be 
taught to manage the psychic aspects of the surgical case. She 
should become adept in answering the questions put to her by the 
patients, with whom she should become acquainted as soon as they 
enter the hospital. She should be taught to answer questions 
diplomatically and to handle the patients firmly yet delicately. 
She should at least superintend the transportation of the patients to 
and from the operating room, and while in the operating room she 
should meet every requirement in offering the patient the maximum 
of comfort. In addition to acting in this capacity she may perform 
a number of other functions in the operating room and become an 
important cog in the surgical wheel. The influence of such an 
individual in a hospital, provided she is happily chosen, will be 
decidedly beneficial. Her constant efforts toward preventing 
patients from suffering discomfort cannot help but be transmitted 
to those about her, especially the student nurses. 

A psycho-anesthetist should look especially to the patient’s 
comfort while he is upon the operating table, and, besides replying 


SURGICAL TECHNIC DEMANDED BY LOCAL ANESTHESIA 161 

tactfully to the patient s questions, she should furnish him with 
water or other refreshments if permitted, apply cold compresses to 
the forehead and eyes, fan him, record the pulse and blood-pressure 
trom time to time, record the amount of anesthetic solution being 
used, record and transmit to the surgeon the impressions of the 
patient and his behavior and reaction to manipulations. She should 
change the position of the table as the surgeon desires, adjust the 
light, look after the ventilation of the operating room, and in a host 
of other ways aid in making the “machine” run as smoothly as 
possible. "W ithin a short time such an individual will learn to 
anticipate the various stages of the induction of the anesthetic 
and of the operation, at which painful sensations may be provoked, 
and by warning the patient, aid the surgeon greatly in meeting 
difficult situations. The psycho-anesthetist can, better than anyone 
else, instruct the patient how to breathe properly when the abdomen 
is opened, so as to avoid expulsive effort and to present the ideal 
“ negative pressure,” which is so much to be desired. She will see 
to it that the patient does not cough, sneeze or laugh at a time when 
such an act would embarrass the surgeon. In the case of nausea 
or vomiting her presence will enable the surgeon to anticipate this 
disaster and to guard against evisceration in case it occurs. To her 
care may be entrusted the decision as to whether or not mixed 
anesthesia should be employed. She can in most instances decide 
quite definitely whether or not the patient is suffering physical or 
psychic injury. Therefore, the presence of a tactful psycho- 
anesthetist, who should not in any way, however, be considered a 
substitute for perfect local anesthesia, is at the same time a most 
valuable adjunct in carrying out the method. 

Surgical Strategy.— It is perhaps unnecessary to remind the 
reader that in the development of strategy, so important in over¬ 
coming obstacles which present themselves, it was necessary to 
make frequent attempts to accomplish what was apparently impos¬ 
sible. A large percentage of the various operative procedures 
carried out in the author’s clinic during the past seventeen years 
has been begun under local anesthesia, each operation being 
carried on until it became evident that general anesthesia must be 
employed for its completion. Every failure has been carefully 
recorded and an effort made to evolve definite strategic methods 
either as to the manner of introducing the anesthetic or the manner 
of applying surgical technic which would meet and overcome the 
obstacles which had made the call for general anesthesia necessary. 
A constant application of this principle soon made apparent the 
fact that for carrying out most of the operative procedures strategic 
methods which would overcome these obstacles could be developed 
in a fair percentage of cases. In this investigation the vast majority 

U 


162 


GENERAL TECHNIC 


of patients presenting themselves have been operated upon under 
local anesthesia alone, the author feeling that for the purpose of 
such investigation the use of preliminary hypodermic medication 
or mixed anesthesia would cause more or less interference with the 
research. While it was most implicitly believed that preliminary 
medication is an important and necessary adjunct to the use of 
local as well as general anesthesia, and that general anesthesia 
should be superimposed upon straight local anesthesia the moment 
the local method for any reason fails to prevent discomfort or to 
permit the completion of the operation in a manner compatible with 
the demands of the case, the adoption of the method referred to 
above has enabled the author to develop a strategy which has, in 
his hands at least, markedly enlarged the scope of local anesthesia. 
Straight local anesthesia, narco-local anesthesia, local anesthesia 
following the use of moderate doses of preliminary hypodermics, and 
mixed anesthesia have all been employed in series after series 
of cases in an effort to determine the merits of each, and it is 
significant that a careful review of our work has established the 
fact that concomitant with an improvement in the technic of induc¬ 
ing local anesthesia, as well as with the establishment of a surgical 
technic compatible with the demands, the necessity for preliminary 
medication and the necessity for resorting to mixed anesthesia has 
become less and less. 

Music.—Appropriate music has been tried and in a large per¬ 
centage of cases it serves to distract the patient’s attention from the 
details of the preparation. He is usually allowed to have the 
Victrola running if he so desires. For the patient who enjoys 
music the apparent time consumed by the preparation and making 
of the operation is somewhat reduced. Music will not reduce the 
pain sense nor will it in any manner act as a substitute for the 
surgeon’s incompetency, but it will, in the absence of pain, con¬ 
tribute a fair measure of solace to a large percentage of patients 
while they are .undergoing operations under local anesthesia, and our 
impression is that it has proven a valuable adjunct in the work. 

Miscellaneous.—Hypodermoclysis (Bartlett).—Bartlett has sug¬ 
gested the use of a small amount of novocain in the fluid used for 
hypodermoclysis in order to make the introduction of fluid beneath 
the skin a painless procedure. This method has been employed 
extensively during the last two years. In order to make certain of 
its efficiency novocain solution has been injected on one side and 
plain saline solution in the other side, as a control; and while 
occasionally the patient may have complained of some distress from 
the weak novocain solution, as a rule the procedure was entirely 
painless. This was practically never the case when saline solution 
alone was employed. Bartlett recommends T \ of 1 per cent solution. 


SURGICAL TECHNIC DEMANDED BY LOCAL ANESTHESIA 1G3 


Ibis method is a most excellent one, and after giving a liter of the 
solution containing the novocain, a second liter may be given 
painlessly without the novocain, owing to the persisting anesthesia. 
( ase No. 15,676 was given 70,000 cc in a seven weeks’ interval by 
the above method. 

Skin-grafting.—Thiersch’s Method.—For several years we have 
transferred r l hiersch grafts under the use of local anesthesia, except 
in cases in which psychic considerations interfered. In a number of 
instances it was possible to perform the operation of skin grafting 
even in children. 


Preparation of Field for Application of Graft .—Either the regional 
method or infiltration block may be used both for the purpose of 
anesthetizing the area from which the skin is to be removed and for 
preparing the field for the reception of the graft. It is well known 
that granulation surfaces are generally devoid of pain sense, except 
at the edges where they join the skin margin. However, the base¬ 
ment membrane from which the granulations arise is usually some¬ 
what sensitive. Topical applications have been suggested as a 
means of anesthetizing granulation areas when preparing them for 
the reception of skin grafts, but for the reasons mentioned this 
method is unsatisfactory, as the solution is, as a rule, unable to 
reach the tissues in which sensation lies. Occasional success of 
this method can perhaps be explained by the assumption that in the 
cases in which preparation of the field was not painful the condition 
was due to lack of acute pain sense in the tissues and not due to the 
application of the anesthetic solution. Where Reverdin grafts are 
to be applied it is, as a rule, unnecessary to anesthetize the recipi¬ 
ent field. 

Provided the field is supplied by sensory nerves which may be 
interrupted by regional methods this is the simplest procedure to 
follow, and the technic for regional blocking should follow the 
general principles laid down for the interruption of these particular 
nerves. However, in the majority of cases regional methods cannot 
be applied, or, at least, may be difficult of application. Under 
such circumstances the simplest procedure to follow is to make an 
infiltration block about and beneath the field. In making this 
block the plan outlined on page 149 should be followed. The 
blocking should begin proximal to the field which is to be 
anesthetized. A subdermal infiltration is produced proximal to 
the field and carried about the field laterally. It is usually unneces¬ 
sary to block the distal side of the field, except in cases in which the 
skin area remains sensitive. When the circumferential subdermal 


infiltration is completed, one may, by continuing the infiltration 
beneath the field of granulation, using long, fine needles and infiltrat¬ 
ing from the proximal side, isolate the basement membrane from the 


1G4 


GENERAL TECHNIC 


underlying tissues. Provided the field is extremely large, one need 
have no hesitation in introducing the needle through the granulation 
area near the center of the field and carrying it in divergent direc¬ 
tions from a central point which has been anesthetized. In very 
large fields this process may be repeated as often as is necessary. 
Following this technic the field may be immediately prepared by 
curettage or by any other method that may be deemed advisable. 

Preparation of the Field for the Removal of the Graft .—The manner 
of anesthetizing the field for the removal of Thiersch grafts will 
depend upon the location from which the graft is to be removed. 
As the surface of the thigh is the area most often used for this 
purpose, and the application of regional anesthesia in this location 
is simple and comparatively certain, the regional method becomes 
the method of choice in this work, One or more nerves, usually the 
femoral, or one of its cutaneous branches, may be interrupted by the 
introduction of a few cubic centimeters of a 2 per cent solution of 
novocain-adrenalin into, or about its trunk, and a sufficient area 
thus prepared for the removal of the graft. 

If, for any reason, however, regional methods are not acceptable, 
isolation of an area by means of a subdermal infiltration is indicated, 
and the same rules as those laid down for the anesthetization of the 
recipient field may be followed. 

x4s a rule, removing skin which has been previously infiltrated 
with solutions containing adrenalin has been avoided. However, 
experiments have shown that pieces of skin so infiltrated have 
resulted in “takes” as frequently as have uninfiltrated pieces of 
skin which were used as controls. 

Pedicle Flaps and Wolff Grafts.—The transferring of pedicle 
flaps and Wolff grafts may be carried out under precisely the same 
technic as that described for Thiersch’s graft. Theoretically, the 
use of adrenalin would not seem advisable. However, in a number of 
instances success has attended the transfer of the pedicle flaps and 
whole skin (Wolff method) where adrenalin solutions had been used. 
The use of adrenalin is practically unnecessary in this work, and 
it may be dispensed with, or reduced to a small amount, as the time 
required for anesthesia is short. It is good practice to anesthetize 
and prepare the recipient field first so that all oozing will have 
subsided by the time the donating field is prepared for the graft. 
Comfort of the patient demands that perfect anesthesia prevail 
and that the operation be carried out with precision and dispatch. 

The transfer of pedicle flaps, always a trying ordeal, upon both 
patient and surgeon, especially when the use of plaster-of-Paris 
fixation is required, may be greatly facilitated by “rehearsing” 
one or more times before the operation, at which time the cast, in 
which the limbs are to be encased, is applied. Before applying 


SURGICAL TECHNIC DEMANDED BY LOCAL ANESTHESIA 165 


the cast a model corresponding to the proposed skin flap should be 
made from a piece of gauze and attached to the skin by adhesive 
tape along a line corresponding to the base of the proposed flap, 
and appropriate pads fitted exactly as they are to be used after the 
completion of the operation, and the cast applied with the limbs 
in proper relation to each other. The cast may then be divided 
and removed. The padding may be retained in its original form, 
labeled and sterilized, to be ready for use after the operation, at 
which time it may be replaced and the plaster east reapplied. This 
method has the great advantage of reducing the time required for 
operation, and decreases the patient’s discomfort and fatigue. It 
is the most effectual means for the prevention of pressure sores, 
which are difficult to avoid if the ordinary method is employed. 
Incidentally the visits of the patient to the operating room preceding 
the time of operation present many advantages from a psychic 
standpoint. 

PHYSIOLOGICAL DIAGNOSTIC TEST UNDER LOCAL 

ANESTHESIA. 

A point mentioned occasionally in this work and one which cannot 
be too strongly stressed relates to the opportunity offered the sur¬ 
geon not infrequently to test out through cooperation of the con¬ 
scious patient the accuracy of diagnosis in eases in which there is 
some doubt. 

One may by manipulating alternately the gall-bladder and appen¬ 
dix, the appendix and the enlarged or cystic ovary or Fallopian tube, 
or visceroparietal adhesions obtain from the patient a definite 
statement as to which maneuver, if any, reproduces the original 
symptoms. 

To the author’s mind this method compares favorably with the 
information gained in making a wide abdominal exploration under 
general anesthesia. 


CHAPTER VI. 


THE ANATOMY OF THE SENSORY NERVOUS 

SYSTEM. 


NERVES OF THE HEAD AND FACE. 

The sensory nerve supply of the head and face is derived almost 
entirely from the trigeminal nerve. Plate I. The -pinal nerves 
coming up from below supply areas in the region of the occiput, 
the ears and the lower jaw. All other portions of the head and 
face are supplied bv the fifth nerve except the outer ear. which is 
supplied by an auricular branch of the vagus as well as the auricular 
branch of the cervical plexus; the tympanic membrane, which is 
supplied by the branches from the glossopharyngeal, the sympathetic- 
carotid plexu> and the otic and petrosal ganglia: the ba^e of the 
tongue, which is also supplied by the latter. 

The Trigeminal Nerve.—The trigeminal nerve is the largest 

cranial nerve and emerges from the Ade of the pons near its upper 

border. It has a motor root which is small and a sensorv root 

% 

which is large. The sensory root fibers arise from the cells of the 

semilunar ganglion and are divided into three main branches, the 

ophthalmic, maxillary and mandibular. Plate II. The ophthalmic 

and maxillarv consist exclusively of sensorv fibers while the 
« • « 

mandibular is joined outside the cranium by a motor root which 
-upplies the muscles of mastication. 

The Ophthalmic Nerve N. Ophthalmicus . — The first sensory 

division of the trigeminal supplies branches to the cornea, the 

ciliary body and the iris: to the lacrimal gland and conjunctiva; 

to a portion of the mucous membrane of the nasal cavity, septum 

and narium, and to the skin of the evelid. evebrow. forehead and 

nose. It enters the orbit through the superior orbital fis?uire just 

after dividing into three branches, the lacrimal, frontal and naso- 

c-iliarv. 

% 

The Lacrimal Nerve n . lacrimal is .—The lacrimal is the 
smallest of the three branches of the ophthalmic. It enters the 
orbit through the narrowest part of the orbital fissure and runs 
along the upper border of the Rectus lateralis, giving off branches 
to the gland, conjunctiva and the skin of the upper eyelid Plate I . 

The Frontal Nerve n. frontalis .—The frontal is the largest 
branch of the ophthalmic, and is practically a continuation of the 
main nerve. It enters the orbit through the superior orbital 



SERVES OF THE HEAD AXD FACE 


167 


fissure, and lies between the Levator palpebne superioris and the 
periosteum. It divides into the supratrochlear and supraorbital . 
(Plate I.) 

The Supratrochlear Branch at. supratrochlearis ), supplies the 

skin of the lower part of the forehead, close to the middle line, 

and sends filaments to the conjunctiva and skin of the upper 

evelid. 

% 

The Supraorbital Branch ( n . supraorbital is) passes through the 
foramen of the same name, giving ofi filaments to the upper eyelid 
and ends in a medial and lateral branch which supplies the integu¬ 
ment of the scalp, reaching nearly as far back as the lambdoidal 
suture. Both branches send twigs to the pericranium. 

The Nasociliary Nerve (r. nasocUiuris ).—The nasociliary, 
or nasal nerve, is intermediate in size between the frontal and 
lacrimal, and passes inward to the medial wall of the orbital cavity 
through the anterior ethmoidal foramen, supplying the mucous 
membrane of the front part of the septum (internal nasal branch) 
and the lateral wall of the nasal cavity, also giving off an external 
nasal branch which supplies the skin of the ala and apex of the 
nose. 

The Long Ciliary Xerres inn. ciliares longi), which arise from 
the nasociliary, are distributed to the iris and cornea. 

Another branch, the lnfratrochlear Xerre (n. infratrochlearis), 
passes to the medial angle of the eye and supplies the skin of the 
eyelid and side of the nose, the conjunctiva, lacrimal sac and 
the caruncula lacrimalis. 

The nasociliary nerve also gives off ethmoidal branches (tin. 
ethmoidales) which supply the ethmoidal cells and sphenoidal 
sinus via the posterior branch, and the short ciliary nerves which 
arise from the ciliary ganglion and supply the ciliaris muscle, iris 
and cornea. 

The Maxillary Nerve (X. Maxillaris ) (Plates I and II .—The 
superior maxillary nerve, or the second division ol the trigeminal, 
is also a sensory nerve. It is intermediate both in position and 
size, between the ophthalmic and mandibular. It leaves the skull 
through the foramen rotundum, crosses the pterygopalatine fossa 
and enters the orbit through the inferior orbital fissure, traverses 
the infraorbital groove and canal in the floor of the orbit and appears 
upon the face at the infraorbital foramen, where it becomes the 
infraorbital nerve. 

Its first branch, the middle meningeal nerve {n. meninges medius) 
travels with the artery of the same name and supplies the dura 
mater. 

The Zygomatic Nerve (n. zygomaticus) , by way of the temporal 
branch of the temporomalar, supplies the skin of the side of the fore- 


168 ANATOMY OF THE SENSORY NERVOUS SYSTEM 


head, and the malar branch of the same nerve supplies the skin on 
the prominence of the cheek. (See Plate I.) 

The Posterior Superior Alveolar Branches {rami alveolares supe- 
riores posteriores) descend on the tuberosity of the maxilla and give 
off branches to the gums and mucous membrane of the cheek. 
They also supply the membrane lining the maxillary sinus and 
send twigs to the molar teeth. (Plate II.) 

The Middle Superior Alveolar Branch (ramus alveolaris supe¬ 
rior medius) supplies the two premolar teeth. 

The Anterior Superior Alveolar Branch (ramus alveolaris supe¬ 
rior anteriores) supplies the upper incisor and canine teeth. It 
also gives off a nasal branch which supplies the mucous membrane 
of the anterior part of the inferior meatus and the floor of the 
nasal cavity. 

The Inferior Palpebral Branches (rami palpebrales inferiores) 
supply the skin and conjunctiva of the lower eyelid. 

The External Nasal Branches (rami nasales externi) supply the 
skin of the side of the nose and the septum mobile nasi. 

The Superior Labial Branches {rami labiates superiores) are 
distributed to the skin of the upper lip, the mucous membrance of 
the mouth and labial glands. This trunk also gives off the palatine 
nerves (nn. palatini), most of which are derived from the spheno¬ 
palatine branches of the maxillary nerve, to the roof of the mouth, 
soft palate, tonsil and lining membrane of the nasal cavity. 

The Anterior Palatine Nerve {n. palatinus anterior) supplies 
the mucous membrane and glands of the hard palate, the gums 
and both surfaces of the soft palate. The posterior inferior branches 
supply the inferior nasal concha, the middle and inferior meatuses 
and both surfaces of the soft palate. (See Fig. 62; page 222.) 

Another branch, the middle palatine nerve (n. palatinus medius) / 
distributes branches to the uvula, tonsil and soft palate. Accord¬ 
ing to Gray this nerve is occasionally wanting. 

The posterior palatine nerve {n. palatinus. posterior) is also dis¬ 
tributed to the uvula, soft palate and tonsil. 

The posterior superior nasal branches ( rami nasales posteriores 
superiores) supply the septum and lateral wall of the nasal fossa, 
the mucous membrane covering the superior and middle nasal 
conchae, the lining of the posterior ethmoidal cells and the posterior 
part of the septum. 

The Mandibular Nerve and Branches (N. Mandibularis; Inferior 
Maxillary Nerve) (Plates I and II).—The mandibular nerve supplies 
the teeth and gums of the mandible, the skin of the temporal region, 


1 Gray’s Anatomy: Twentieth edition, p. 893. 


PLATE I 



Sensory Areas of the 
Three Divisions 


Head, Showing the General Distribution of the 
of the Fifth Nerve. (Modified from Testut.) 

































PLATE II 



Auriculotemporal 

nerve 


Sensory root 
Motor root 


Distribution of the Maxillary and Mandibular Nerves, and 
the Submaxillary Ganglion. (Gray.) 



































PLATE III 



AURICULO¬ 

TEMPORAL 


BUCCINATOR 


MYLOHYOID 


LINGUAL 


ANTERIOR 

AURICULAR 

BRANCHES TO 
MEATUS 


POSTERIOR TEMPORA 
ZYGOMATICOFACIAL 
TEMPORAL BRANCH 
OF BUCCAL 


NFRAORBITAL 


RTICULAR 


M E 


NTAL 


INFERIOR 

DENTAL 


PAROTID 
BRANCHES 
COMMUNICATING 
TO FACIAL 


Mandibular Division of the Trifacial Nerve 


(Testut.) 






















PLATE IV 



Hypoglossal Nerve, Cervical Plexus, and their Branches. (Gray.) 























































PLATE V 



Termination 
of supratrochlear 
of infratrochlear 
of nasociliary 


The Nerves of the Scalp, Face, and Side of Neck. (Gray.) 



















































































PLATE VI 


Lateral anterior thoracic 


Medial anterior thoracic 


M usculocutaneous 


- Median 


Med. antibrach. cidaneous 


Radial 

Deep hr. of radial 



Superfic. br. of radial 


Volar interosseous 


Deep branch 


Nerves of the Left Upper Extremity. (Gray.) 













































PLATE VII 



Cutaneous Nerves of Right Upper Ex- Diagram of Segmental Distribution of the Cuta- 
tremity. Anterior Vievv. (Gray.) neons Nerves of the Right Upper Extremity. 

Anterior View. (Gray.) 


Intercostobrachial 
































































PLATE VIII 




Cutaneous Nerves of Right Upper 
Extremity. Posterior View. 
(Gray.) 


Diagram of Segmental Distribution of the 
Cutaneous Nerves of the Right Upper Ex¬ 
tremity. Posterior View. (Gray.) 






































































NERVES OF THE HEAD AND FACE 


169 


the auricle, the lower lip, the lower part of the face, the mucous 
membrane of the anterior two-thirds of the tongue and the muscles 
of mastication via the motor branches. 

the temporomandibular joint is supplied by the masseteric 
nerve ( n. massetericus). (Plate III.) 

r l he skin over the buccinator and the mucous membrane lining 
its inner surface are supplied by the buccinator nerve (n. buccin- 
atorus; long buccal nerve). (Plates II and III.) 

An important branch is the auriculotemporal nerve (n. auriculo- 
temporalis) (Plate II) which divides into two branches, straddling 
the middle meningeal artery and running backward past the neck 
of the mandible, ascending over the zygomatic arch, which supplies 
the skin covering the front of the helix and tragus, via tin. auriculares 
anteriores and the temporal region via rami tempo rales superficiales. 
(Plate I.) 

The branches to the external acoustic meatus (n. meatus auditorii 
externi) supply the skin lining of the ear and the tympanic mem¬ 
brane. 

The Lingual Nerve (n. lingualis) (Plates II and III) supplies the 
mucous membrane of the anterior two-thirds of the tongue, the 
mucous membrane of the mouth and the gums. 

The Inferior Alveolar Nerve ( n. alveolaris inferior; inferior 
dental nerve) (Plate III) of the mandibular nerve, gives off branches 
to supply the canine and incisor teeth via the incisive branch, the 
molar and premolar teeth via the dental branches, and the skin 
of the chin and mucous membrane of the lower lip via the mental 
nerve. (Plate I.) 

The Facial Nerve (N. Facialis; Seventh Nerve).— The facial 
nerve possesses some sensory fibers known as the greater superficial 
petrosal nerve, which supplies the mucous membrane of the soft 
palate and the nervus intermedins (pars intermedii of 11 risberg), 
which supplies the anterior two-thirds of the tongue and the middle 


ear. 


The Glossopharyngeal Nerve (N. Glossopharyngeus; Ninth A erve). 
—This nerve gives off a few sensory filaments to the mucous 
membrane of the pharynx, fauces and palatine tonsil (big. 62, 
page 222) and the nerve of taste to the posterior one-third of the 
tongue (fasciculus solitarius). 

The Vagus Nerve (N. Vagus; Tenth Nerve; Pneumogastric Nerve). 
—This nerve gives off* a branch, the superior laryngeal (n. laryn - 
geus superior) , the internal branch (ramus internus) of which supplies 
the mucous membrane of the larynx, the epiglottis, the base of 
the tongue, the epiglottic glands, the aryepiglottic fold and the 
mucous membrane surrounding the entrance of the larynx as low 
down as the vocal folds. 


170 ANATOMY OF THE SENSORY NERVOUS SYSTEM 


It also gives off the recurrent nerve (n. recurrens; inferior or 
recurrent laryngeal nerve), which communicates with the internal 
branch of the superior laryngeal and gives off a few filaments to 
the mucous membrane of the lower part of the larynx. 

Another branch, the auricular branch ( ramus auricularis; nerve 
of Arnold), which reaches the surface by passing through the tym¬ 
panomastoid fissure, supplies the back of the auricula and the 
posterior part of the external auditory meatus. 

THE SPINAL NERVES (NERVI SPINALES). 

The spinal nerves emerge from the spinal canal through the 
intervertebral foramina. There are 31 pairs, as follows: cervical, 
8; thoracic, 12; lumbar, 5; sacral, 5; coccygeal, 1. 

The Cervical Nerves (Nn. Cervicales).— The cervical nerves are 
8 in number. The anterior divisions of the upper four cervical 
nerves unite to form the cervical plexus (Plate IV). Those of the 
lower four cervical together with the greater part of the first thoracic 
form the brachial plexus. (Fig. 36.) 

The Cervical Plexus ( Plexus Cervicalis). —The cervical plexus is 
situated opposite the upper four cervical vertebrae and is beneath 
the sternocleidomastoideus. It possesses two groups of branches, 
the superficial and deep. 

The superficial branches are as follows: 

The Smaller Occipital Nerve ( n . occipitalis minor), (Fig. 41, page 
186) arising from the second cervical, sometimes also from the 
third, and passing upward along the side of the head, behind the 
ear, supplies the skin in this region. It gives off an auricular 
branch to the upper and back part of the ear. 

The Great Auricular Nerve (n. auricularis magnus), (Fig. 41, 
page 186) arising from the second and third cervical nerves, gives 
off an anterior branch (ramus anterior; facial branch) to the skin 
of the face over the parotid gland, and a posterior branch (ramus 
posterior; mastoid branch) to the skin over the mastoid process 
and on the back of the lower part of the ear. It also gives off a 
branch which pierces the ear and is distributed to the lobule and 
lower part of the concha. 

The Cutaneous Cervical (n. cutaneus colli; superficial or trans¬ 
verse cervical nerve), Plate V, arises from the second and third cer¬ 
vical nerves, turns around the posterior border of the sternocleido¬ 
mastoideus at about its middle, passes obliquely forward and 
supplies the antero-lateral parts of the neck. This nerve per¬ 
forates the deep cervical fascia near the anterior border of the 
muscle and makes its division beneath the platysma. Its ascend¬ 
ing branches (rami superiores) pass upward to the submaxillary 


TIIE SPINAL NERVES 


171 


legion and supply the skin of the upper and front part of the neck. 
Its descending branches ( rami inferiores) supply the skin of the 
side and front of the neck as low as the sternum. 

The Supraclavicular Aerves ( nn. supraclaviculares; descending 
blanches (1 late \ ), arise from the third and fourth cervical nerves. 



Ple^u4 
bracki alts' 


A 


In-terdogtal 

muscles: 

and 

Side arul 
front of 
dieSh 


Fig. 36.—A, origin of the nerves to be anesthetized in radical breast operation; 
B, anatomy of superficial nerves of upper part of chest; C, branches of brachial 
plexus supplying muscles beneath the breast. A. 1, N. phrenicus; 2, Nn. supra¬ 
claviculares (integument of chest down to fourth rib); 3, N. suprascapularis; 4, N. 
subclavius; 5, N. thoracalis longus (serratus magnus); 6, Nn. thoracales anteriores 
(pectoral muscles); 7, N. intercostalis I; 8, N. intercostalis II; 9, N. intercostalis III; 
10, N. intercostalis IV; 11, N. intercostalis V; 12, N. intercostalis VI. B. 1, M. 
trapezius; 2, Nn. supraclaviculares posteriores; 3, Nn. supraclaviculares posteriores; 
4, M. sternocleidomastoideus; 5, V. jugularis externa; 6, M. platysma; 7, Nn. supra¬ 
claviculares anteriores; 8, Nn. supraclaviculares medii. C. 1, N. subclavius; 2, 
V. et A. subclavius; 3, Nn. thoracales anteriores; 4, clavicle; 5, N. suprascapularis; 
6, M. deltoideus; 7, M. pectoralis minor and major; 8, N. thoracalis longus; 9, M. 
serratus anterior; 10, N. phrenicus; 11, clavicle; 12, N. intercostalis I; 13, M. pectoralis 
major; 14, M. pectoralis minor. 

































172 


ANATOMY OF THE SENSORY NERVOUS SYSTEM 


They descend in the posterior triangle of the neck and become 
cutaneous near the clavicle, where they divide into anterior, middle 
and posterior branches. 

The anterior supraclavicular nerves (nn. supraclaviculares anteriores; 
suprasternal nerves) supply the skin as far as the midline and also 
the sternoclavicular joint. 

The middle supraclavicular nerves (nn. supraclavicular es medii; 
supraclavicular nerves ) supply the skin over the peetoralis major 
and deltoideus. 

The posterior supraclavicular nerves (nn. supraclavicular es pos- 
teriores; supraracromial nerves) supply the skin of the upper and 
posterior parts of the shoulder. 

The Brachial Plexus (plexus hrachialis) (Fig. 36, A and C).— 
The brachial plexus is formed by the union of the anterior divisions 
of the lower four cervical nerves, combined with the anterior 
division of the first thoracic. The plexus extends from the lower 
part of the side of the neck to the axilla, its direction being almost 
at right angles to the clavicle at the middle point. 

This plexus supplies the whole of the upper extremity, and 
fortunately, from the standpoint of the local anesthetist, its bundles 
form a more or less compact cord from a point an inch or more 
above the clavicle to a point the same distance below this bone. 

Above the clavicle the brachial plexus gives off the long thoracic 
nerve (n. thoracalis longus; external respiratory nerve of Bell; pos¬ 
terior thoracic nerve) to the serratus anterior (Fig. 36, C.). 

The Dorsal Scapular Nerve (n. dorsalis scapulae; posterior scapular 
nerve) supplies the rhomboidei. 

The Suprascapular (n. suprascapularis) supplies the supra spi¬ 
na t us and infraspinatus muscles and the shoulder joint. 

The pectorales major and minor are supplied by the anterior 
thoracic nerve (n. thoracales anteriores), which are given off just below 
the clavicle. (Fig. 36, C [3].). 

A number of other muscular branches are given off in the axillary 
region, viz., nn. subscapular es. 

Practically, the brachial plexus must be reached near its origin, 
preferably just above the clavicle, for the purpose of producing 
anesthesia of the upper arm and shoulder joint. The forearm 
may be anesthetized in the same manner, or from this region dis- 
tallv the individual nerves may be interrupted. 

The divisions of the brachial plexus that concern us are the 
median, ulnar and radial. 

The Median Nerve (n. medianus) (Plate VI) extends along the 
middle of the arm and forearm to the hand. Its fibers are derived 
from the sixth, seventh and eighth cervical and first thoracic 
nerves. It usually lies in front of the brachial artery at the elbow 


THE SPINAL NERVES 


— * , 
i O 


joint and becomes more superficial as it approaches the wrist, 
where it is found between the tendons of the flexor digitorum 
sublimis and the flexor carpi radialis. This nerve gives off prac¬ 
tically no branches in the arm, but supplies important sensory 
branches to the elbow joint. It is the important nerve of sensa¬ 
tion of the palm of the hand via the medial and lateral branches 
of the ramus cutaneus palmaris n. mediani. (Plates MI and 
VIII.) 

The Ulnar Nerve (n. ulnaris) (Plate VI), derived from the eighth 
cervical and first thoracic nerves, lies along the medial side of the 
arm and supplies the elbow, where it rests in a groove between the 
medial epicondyle and the olecranon; in the forearm it is sub¬ 
fascial. At the wrist it divides into a dorsal and a volar branch. 
It gives off important articular branches to the elbow joint, and 
with the median nerve supplies sensation to the palm of the hand 
via ramus cutaneus palmaris of n. ulnaris. (Plate MI.) 

The Radial Nerve (n. radialis); musculospiral nerve (Plate VI), is 
the largest branch of the brachial plexus and arises from the poste¬ 
rior cord. Therefore, it comes from the fifth, sixth, seventh and 
eighth cervical and first thoracic nerves. It gives off* several muscu¬ 
lar branches, a posterior brachial cutaneous nerve (n. cutaneus 
hrachii posterior), which supplies the skin on the dorsal surface of the 
arm nearlv as far as the elbow, and the dorsal antibraehial cutane- 
ous nerve (n. cutaneus antibrachii dorsalis), which supplies the skin of 
the lower half of the arm. Ultimately the radial nerve divides into 
four digital nerves, supplying the skin on the radial side and ball 
of the thumb, the radial side of the index finger, the adjoining 
sides of the index and middle fingers and the adjoining sides of 
the middle and ring fingers. (Plates Xll and VIII.) 

The Thoracic Nerves ( Nn . Thoracales) (Plates IX and X).—The 
thoracic nerves are twelve in number on either side. Eleven are 
termed intercostal and the twelfth lies below the last rib. The 
intercostal nerves (nn. intercostales) are distributed to the parietes 
of the thorax and abdomen. The first two nerves also supply 
fibers to the upper limb, the next four are distributed over the 
thorax, the lower five supply the thorax and abdomen and the 
twelfth supplies the abdominal wall and the skin of the buttock. 

The posterior divisions arise close to the point of origin from 
the spine and supply the muscles and skin of the posterior part of 
the trunk via the medial and lateral branches. (Fig. 37.) 

The first thoracic nerve sends a branch to the brachial plexus, 
and gives off a smaller branch, the first intercostal nerve, to the 
front of the thorax. 

The anterior divisions of the second, third, fourth, fifth and 
sixth thoracic nerves, which supply the thorax exclusively, run 


174 ANATOMY OF THE SENSORY NERVOUS SYSTEM 


forward in the intercostal spaces below the vessels. Each gives 
oft* a lateral cutaneous branch, ramus cutaneus lateralis (Fig. 37) at 
a point midway between the spine and sternum. 

The anterior branches of rami cutanei laterales run forward near 
the sternal border between the intercostal muscles to the side 
and the forepart of the chest. They are easily located by reason 
of their relation with the ribs. In order that their cutaneous dis¬ 
tribution to the forepart of the chest and the skin over the mamma 
may be interrupted it is necessary to block them at a point proximal 
to the origin of the lateral cutaneous rami. 



Fig. 37. —Diagram of the course and branches of a typical intercostal nerve. 

(Gray.) 


The posterior branches of rami cutanei laterales supply the 
skin over the scapula and Latissimus dorsi. 

A branch of the second intercostal nerve, which does not divide 
into an anterior and a posterior branch, named the intcrcosto- 
brachial nerve, (Plate IX) supplies the skin of the upper half of 
the medial and posterior part of the arm. Frequently a branch 
from the third intercostal sends filaments to the axilla and medial 
side of the arm. 

The anterior divisions of the seventh, eighth, ninth, tenth and 
eleventh thoracic nerves are continued onward to supply the 

















THE LUMBOSACRAL PLEXUS 175 

abdominal wall and are called the thoracico-abdominal intercostal 
nerves.' I hey lie betweem the internal oblique and the trans- 
versalis, and perforate the sheath of the rectus abdominis, ending 
as anterior cutaneous branches to the skin of the abdomen. The 
origin and arrangement of the branches correspond with that of 
the other intercostal nerves. The lateral cutaneous branches supply 
the skin of the abdomen and back. 

The anterior division of the twelfth thoracic nerve communicates 
with the iliohypogastric nerve, lies in front of the quadratus lum- 
borum and runs in the same plane and is distributed in the same 
manner as the lower intercostal nerves. Its lateral cutaneous 
branch is large and perforates the internal and external oblique 
and descends over the iliac crest to supply the skin on the front 
part of the gluteal region, nearly as far as the greater trochanter 
(Plates IX and X). 

THE LUMBOSACRAL PLEXUS (PLEXUS LUM.BOSACRALIS). 

The anterior divisions of the lumbar, sacral and coccygeal nerves 
form the lumbosacral plexus. It is frequently joined by a branch 
from the twelfth thoracic. This plexus is divided into three parts 
—the lumbar, sacral and pudendal plexuses. 

The Lumbar Nerves ( Nn. Lumbales, Plate XI).—The anterior 
divisions of the lumbar nerves (rami anteriores) pass obliquely 
outward behind the psoas major. The first three and a portion 
of the fourth form the lumbar plexus. The smaller part of the 
fourth joins with the fifth to form the lumbosacral trunk, which 
assists in the formation of the sacral plexus (Plate XIV). The 
arrangement of this plexus is not constant. The first lumbar nerve, 
frequently accompanied by a twig from the last thoracic, divides into 
an upper and lower branch. The upper and larger branch divides 
into the iliohypogastric and ilioinguinal nerves, which are of great 
importance in connection with operations for inguinal hernia. 
The lower and small branch communicate with a branch of the 
second lumbar to form the genitofemoral nerve. The remaining 
branches of the plexus divide into ventral and dorsal divisions, 
the obturator nerve being formed by the ventral division of the 
second nerve, combined with the ventral divisions of the third and 
fourth nerves. The lateral femoral cutaneous nerve is formed 
bv the smaller dorsal divisions of the second and third nerves, 
the femoral nerve being formed hy larger branches from the dorsal 
divisions of the second and third, combined with a branch from 
the fourth. 

The Iliohypogastric Nerve (n. iliohypogastricus). (Plate X).— r l his 
nerve is of the greatest importance from the standpoint of local 


176 ANATOMY OF THE SENSORY NERVOUS SYSTEM 


anesthesia. It arises from the first lumbar nerve, passes in front of 
the quadratus lumborum to the iliac crest, perforates the transversus 
abdominis near the iliac crest, and beneath the internal oblique 
divides into a lateral cutaneous branch (ramus cutaneus lateralis; 
iliac branch ) and an anterior cutaneous branch ( ramus cutaneus 
anterior; hypogastric branch). 

The lateral branch (ramus cutaneus lateralis) pierces the internal 
and external oblique above the iliac crest and is distributed to the 
skin of the gluteal region just behind the lateral cutaneous branch 
of the last thoracic nerve. (Plates IX and XIII.) 

The anterior branch (ramus cutaneus anterior) runs between the 
internal oblique and the transversalis to a point about one inch 
above the external ring, and is distributed to the skin of the hypo¬ 
gastric region. (Plate XII.) 

The iliohypogastric nerve communicates with the last thoracic 
and ilioinguinal nerves. (Plate XI.) 

The Ilioinguinal Nerve (n. ilioingninalis) . —This nerve is also 
important in its relation to local anesthesia. It is smaller than the 
iliohypogastric, and arises from the first lumbar nerve. It lies 
just below the iliohypogastric, perforates the transversus abdominis 
in front of the iliac crest, pierces the internal oblique, distributing 
filaments to it, and, accompanying the spermatic cord, is dis¬ 
tributed to the skin of the upper and medial part of the thigh. 
(Plate XII.) It supplies the upper part of the scrotum and root of 
the penis in the male and the mons pubis and labium majus in the 
female. This nerve and the iliohypogastric complement each 
other, the latter often entirely replacing the ilioinguinal, which 
may be absent. 

The Genitofemoral Nerve (n. genitofemoralis; genitocrural nerve).— 
This nerve arises from the first and second lumbar nerves. It 
lies more deeply under the peritoneum and divides into the external 
spermatic and lumboinguinal nerves. (Plate XIV.) 

The external spermatic nerve (n. spermaticus externus; genital 
branch of the genitofemoral) passes through the inguinal canal, 
descends behind the spermatic cord to the scrotum, supplies the 
cremaster, and sends some fibers to the skin of the scrotum. In 
the female it accompanies the round ligament of the uterus. 

The lumboinguinal nerve (n. lumboinguinalis; femoral or crural 
branch of the genitofemoral) accompanies the external iliac artery, 
enters the sheath of the femoral vessels and supplies the skin on 
the anterior surface of the upper part of the thigh (Plate XII.) 

The Lateral Femoral Cutaneous Nerve (n. cutaneus femoralis 
lateralis; external cutaneous nerve) arises from the posterior divisions 
of the second and third lumbar nerves (Plate IX) , having an anterior 


PLATE IX 



INTERCOST O- 
BRACHIAL 


ANTERIOR CUTANEOUS 
NERVES OF THORAX 


LATERAL CUTA- ) 
NEOUS OF Ml TO - 
XI THORACIC ) 


ANTERIOR 

CUTA- 

NEOUS 

j nerves 

OF 

| ABDOMEN 


ANT. CUTANEOUS 
OF X, XI, AND 
XII THORACIC 


LATERAL CUTA¬ 
NEOUS OF ILIO¬ 
HYPOGASTRIC 


LATERAL CUTA¬ 
NEOUS OF XII 
THORACIC 


Cutaneous Distribution of Thoracic Nerves 


(Testut.) 

















































































PLATE X 



INTER NAL 
CUTANEOUS 


'/J/jiL'I- 


LATERAL CUTANEOUS 
BRANCHES OF III 
TO XI THORACIC 


LATERAL CUTA 
NEOUS OF XII 
THORACIC 





Intercostal Nerves, the Superficial Muscles having been Removed. 

(Testut.) 
















PLATE XI 



The Lumbar Plexus and its Branches. (Gray.) 



















PLATE XII 



Cutaneous Nerves of Right Lower 
Extremity. Front View. 


Diagram of Segmental Distribution of 
the Cutaneous Nerves of the Right 
Lower Extremity. Front View. 


























































PLATE XIII 


Fig. 1. 


Fig. c 2. 


Fig. 3. 



Common 

'peroneal 


Peroneal 

anastomotic 


Fia 1 —Cutaneous Nerves of Right Lower Extremity. Posterior View. (Gray.) 

Fig! 2*—Diagram of the Segmental Distribution oi the Cu.aneous Nerves of the Right Lower 
iremity. Posterior View. (Gray.) 

Fig. 3.—Nerves of the Right Lower Extremity. Posterior View. 
























































































PLATE XIV 



INFERIOR 

PUDENDAL 


EXTERNAL SPER¬ 
MATIC BRANCH OF 
GENITO-CRURAL 
LUMBO-INGUINAL 
BRANCH OF 
GENITO-CRURAL 


LEFT DORSA 
DORSAL NERV 
OF PEN IS 


FI FTH 
M BAR 


SYMPATHETIC 

TRUNK 

LUM BO-SACRAL 
CORD 

SUPERIOR 
GLUTEAL 
RAMUS 

lit COMMUNICANS 


»S"_ 

S 1 


VISCERAL 
BRANCHES 
NERVE TO 
LEVATOR ANI 

'...HEMORRHOIDAL BRANCH 
OF PUD1C 

PUDENDAL 
PERI NEAL 

POST. FEMORAL 


EXTERNAL SUPER¬ 
FICIAL PERINEAL 
.INTERNAL SUPER¬ 
FICIAL PERINEAL 


''NERVE TO BULB 


LATERAL FEMORA 


GENITO¬ 

FEMORAL 


Sacral Plexus of the Right Side. (Testut.) 























PLATE XV 



SPLANCHNIC 
GANGLION 
GREATFR 
SPLANCH N 1C 


LESSER 
SPLANCHNIC 


BRANCH OF VAGUS 
TO CELIAC GANGLION 

CELIAC AXIS 


RIGHT VAGUS 


INFERIOR CER¬ 
VICAL GANGLION 


THORACIC NERVE 
RAMI COMMUNICANTE 


VISCERAL 

BRANCHES 


VISCERAL 

BRANCHES 


THORACIC CHAIN 
OF GANGLIA 


LOWEST 

SPLANCHNIC 


QUADRATUS 

LUMBORUM 


SEMILUNAR GANGLION 
SUPERIOR MESENTERIC 
ARTERY AND PLEXUS 

CELIAC PLEXUS 


RENAL PLEXUS 


Plan of Right Sympathetic Cord and Splanchnic Nerves. 


(Testut.) 


















































PLATE XVI 


D iaphragmatic 
ganglion 

Suprarenal gland 


Hepatic 

artery 


Greater 

splanchnic 

nerve 

Right 

celiac 

ganglion 


Aorticorenal ganglion 

Lowest splanchnic 
nerve 


Renal artery 


Communicating branch 



Left celiac ganglion 

Superior mesenteric 
artery 

Greater splanchnic nerve 
Lesser splanchnic 
nerve 

Aorticorenal 
ganglion 


Renal artery 


Superior mesenteric 
ganglion 


Branch to aortic plexus 


Sympathetic trunk 


Branch to aortic plexus 


Inferior mesenteric artery 


Inferior mesenteric 
ganglion 


Sacrovertebral angle 

Common iliac vein 
Common iliac artery 


Abdominal Portion of the Sympathetic Trunk with the Celiac and 

Hypogastric Plexuses. (Henle.) 





















































































































































TIIE LUMBOSACRAL PLEXUS 


177 


branch which supplies the skin on the anterior and lateral parts of 
the thigh as far as the knee, and a posterior branch which pierces 
the fascia lata, supplying the skin from the level of the greater tro¬ 
chanter to the middle of the thigh posteriorly, (Plates XII and 

XIII). 

The Obturator Nerve (n. obturator ins) arises from the anterior 
divisions of the second, third (largest) and fourth lumbar nerves, 
passes behind the common iliac vessels lateral to the ureter, entering 
the thigh through the upper part of the obturator foramen, where 
it divides into an anterior and a posterior branch. (Plate XI.) 

The anterior branch (ramus anterior) gives off* branches to the 
hip joint and to the skin of the tibia! side of the leg as low down 
as its midpoint. 

The posterior branch (ramus posterior) supplies the obturator, 
muscles and usually gives off an articular branch to the knee joint. 

The Accessory Obturator Nerve in. obturatorius accessorius), 
according to Gray, is present in 29 per cent of cases. It supplies 
the capsule of the hip joint. 

The Femoral Nerve (n. femoralis; anterior crural nerve), the largest 
branch of the lumbar plexus, and an important sensory nerve, 
arises from the dorsal divisions of the second, third and fourth 
lumbar nerves (Plate XI). A large part of the nerve is continued 
to the thigh, where it gives off anterior cutaneous branches, which 
comprise the intermediate cutaneous nerve ( ramus cutaneus ante¬ 
rior; middle cutaneous nerve) and the medial cutaneous nerve ( ramus 
cutaneus anterior; internal cutaneous nerve). (Plate XII.) 

The intermediate cutaneous nerve pierces the fascia lata about 
7.5 cm. below Poupart’s ligament and divides into two branches 
which travel together along the forepart of the thigh, supplying 
the skin as low as the front of the knee. These, with the medial 
cutaneous nerve and the infrapatellar branch of the saphenous, 
form the patellar plexus. 

The medial cutaneous nerve supplies the medial side of the thigh. 
(Plate XIII.) 

The Saphenous Nerve (n. saphenous; long or internal saphenous 
nerve) is the largest cutaneous branch of the femoral nerve. (Plate 
XII.) It passes along the tibia! side of the leg, accompanied by the 
great saphenous vein, and at the lower third of the leg divides into 
two branches, one of which continues along the margin of the tibia, 
supplying the front and medial sides of the leg, ending at the 
ankle joint; the other passes in front of the ankle and is distrib¬ 
uted to the skin of the medial side of the foot as far as the ball 
of the great toe. The muscular branches of this nerve supply 
the knee joint. 


12 


178 ANATOMY OF THE SENSORY NERVOUS SYSTEM 


THE SACRAL AND COCCYGEAL NERVES (NN. SACRALES 
ET COCCYGEUS). (PLATE XIV.) 

The anterior divisions of the sacral and coccygeal nerves form 
the sacral and pudendal plexuses (Plate XIV). These nerves lie 
along the back of the pelvis between the piriformis and the pelvic 
fascia, and are therefore in front of the sacrum. They furnish ven¬ 
tral branches to numeruos muscles of the buttock and thigh, their 
most important contribution being the sciatic and pudendal nerves. 

The first and second branches of these plexuses, the superior 
and inferior gluteal nerves, supply the gluteal muscles and the 
tensor fasciae latae. 

The Posterior Femoral Cutaneous Nerve (n. cutaneus femoralis 
posterior; small sciatic nerve) supplies the skin of the perineum, 
the posterior surface of the thigh and leg and the lower and lateral 
gluteal regions. (Plate XIII.) It arises from the dorsal divisions 
of the first and second and the ventral divisions of the second and 
third sacral nerves, and passes through the greater sciatic foramen, 
lying beneath the gluteus maximus, and in the thigh, beneath 
the fascia lata (Plate XIV). It passes over the long head of the 
biceps femoris to the back of the knee, and accompanies the small 
saphenous vein to about the middle of the back of the leg. It gives 
off three or four gluteal branches which supply the skin over the 
lower and lateral part of the gluteal muscle. 

The perineal branches ( rami perineales) are important. They 
are distributed to the upper and medial side of the thigh. The 
inferior pudendal (long scrotal nerve) passes in front of the tuberosity 
of the ischium, pierces the fascia lata, and in the perineum lies 
just beneath the superficial fascia, supplying the skin of the scrotum 
in the male (Fig. 138, page 343; Fig. 140, page 345) and the labium 
majus in the female. Practically the whole of the skin covering 
the back and medial side of the thigh and the upper part of the 
back of the leg and the popliteal fossa is supplied by this nerve. 
(Plate XIV.) 

The Sciatic Nerve ( n . ischiadicus; great sciatic nerve) is formed 
by branches of the fourth and fifth lumbar, as well as the first, 
second and third sacral nerves and is the largest nerve in the body. 
It leaves the pelvis through the greater sciatic foramen, lies between 
the greater trochanter of the femur and the tuberosity of the 
ischium, and at the lower third of the thigh it divides into the 
tibial and common peroneal nerves (Plate XIII). 

It gives off articular branches ( rami articulares) to the hip joint. 
These are sometimes derived from the sacral plexus. 

It also gives off muscular branches ( rami musculares ) to the 
muscles of the thigh. 


THE SACRAL AND COCCYGEAL NERVES 


179 


The Tibial Nerve {n. tibialis; internal popliteal nerve) is the largest 
branch of the sciatic. It arises from the ventral branches of the 
fourth and fifth lumbar and the first, second and third sacral nerves. 
It lies at about the middle of the popliteal fossa and accompanies 
the popliteal artery and the posterior tibial vessels down the back 
of the leg. At a point between the heel and the internal malleolus 
of the tibia it divides into the medial and lateral plantar nerves. 
(Figs. 38 and 39.) In the leg the tibial nerve lies deep beneath the 
muscles of the calf. (See Fig. 100, page 274.) Lower down it lies 
beneath the deep fascia. It gives off articular branches ( rami 
articulares) to the knee joint and the ankle joint, and muscular 
branches ( rami musculares) to the muscles of the leg. 



Fig. 38.—Medial view of nerve supply of ankle. 1, V. et A. tibialis posterior and 
N. tibialis; 2, N. saphenus; 3, V. saphena magna; 4, N. saphenus rami cutanei 
mediales; 5, N. plantaris medialis (tibial); 6, N. tibialis rami calcanei mediales. 


The medial, sural cutaneus nerve (n. cutaneus suree medialis; 
n. communicans tibialis) lies along the lateral margin of the tendo 
calcaneus, behind the external malleolus, unites with the anasto¬ 
motic ramus of the common peroneal to form the sural nerve, 
which becomes the lateral dorsal cutaneous nerve supplying the 
lateral side of the foot and the little toe (Plate XII). 

The medial calcaneal branches (rami calcanei mediales; internal 
calcaneal branches) supply the skin of the heel and the medial side 
of the sole of the foot (Fig. 38). 

The medial plantar nerve (n. plantaris medialis (Fig. 38); internal 
plantar nerve), gives off cutaneous branches to the skin of the sole 
of the foot, muscular branches to the muscles of the foot and 
articular branches to the articulations of the tarsus and meta¬ 
tarsus. It gives off a proper digital plantar nerve, which supplies 
the flexor hallucis brevis and the skin on the medial side of the 
great toe, and finally divides into three common digital nerves 























ISO 


ANATOMY OF THE SENSORY NERVOUS SYSTEM 


(' nn . digitales plantares communes). The first common digital 
nerve supplies the adjacent sides of the great and second toes, the 
second the adjacent sides of the second and third toes, and the 
third the adjacent sides of the third and fourth toes (Fig. 39). 

The lateral plantar nerve (n . plantaris lateralis; external plantar 
nerve), (Fig. 39), supplies the skin of the fifth toe and the latter 
half of the fourth, much as does the ulnar nerve in the hand. 



Fig. 39. — Nerve supply of foot-plantar 
view. 1, N. digitales plantares proprii; 
2, N. digitales plantares communes; 3, 
N. plantaris medialis; 4, N. plantaris 
lateralis. 



Fig. 40. — Nerve supply of foot-dor¬ 
sal view. 1, Vena saphena magna; 2, 
N. cutaneus dorsalis intermedius; 3, 
N. cutaneus dorsalis medialis; 4, Nn. 
digitales dorsales hallucis lateralis et 
digiti secundi medialis (peroneus pro¬ 
fundus). 


The Common Peroneal Nerve (n. peronaeus communis; external 
popliteal nerve; peroneal nerve) arises from the dorsal branches of 
the fourth and fifth lumbar and the first and second sacral nerves. 
It lies along the lateral side of the popliteal fossa, winds around 
the neck of the fibula and gives off articular branches to the knee. 

The lateral sural cutaneus nerve (n. cutaneus surce lateralis; lat¬ 
eral cutaneous branch) supplies the skin of the posterior and lateral 
surfaces of the leg (Plate XIII). 









































THE PUDENDAL PLEXUS AND BRANCHES 


181 


The common peroneal nerve at its bifurcation gives off the 
deep and superficial peroneal nerves. 

7 he Deep Peroneal Nerve (■ n. peronoeus profundus; anterior 
tibial nerve) travels in conjunction with the anterior tibial artery 
to the front of the ankle joint. In the leg it gives off muscular 
branches, an articular branch to the ankle joint, and a lateral 
terminal branch supplying the muscles, as does the medial terminal 
branch. The metatarsophalangeal joint of the great toe is supplied 
by an interosseous branch. 

The Superficial Peroneal Nerve (n. peronoeus arid superficial is; 
musculocutaneous nerves) supplies the skin over the greater part 
of the dorsum of the foot. It pierces the deep fascia at the lower 
third of the leg and divides into the medial and intermediate dorsal 
cutaneous nerves. 

The medial dorsal cutaneous nerve (n. cutaneus dorsalis medialis; 
internal dorsal cutaneous branch), Fig. 40, passes in front of the 
ankle joint, divides into two digital branches, one supplying the 
medial side of the great toe and the other the adjacent side of the 
second and third toes. This nerve supplies the skin of the medial 
side of the foot and ankle. 

The intermediate dorsal cutaneous nerve (n. cutaneus dorsalis 
intermedins; external dorsal cutaneous branch) Fig. 40, passes along 
the lateral part of the dorsum of the foot and supplies the con¬ 
tiguous sides of the third and fourth, and of the fourth and fifth 
toes. It also supplies the skin on the lateral side of the foot and 
ankle. 

The branches of the superficial peroneal nerve supply the skin 
on the dorsal surface of all the toes excepting the outer side of 
the little toe, and the adjoining sides of the great and second toes, 
the former being supplied by the lateral dorsal cutaneous nerve 
and the latter by the medial branch of the deep peroneal nerve. 
(Fig. 40.) 

THE PUDENDAL PLEXUS AND BRANCHES (PLEXUS 
PUDENDUS). (PLATE XIV.) 

The pudendal plexus is not sharply marked off from the sacral 
plexus. It is usually formed by branches from the anterior divi¬ 
sions of the second and third sacral nerves, the whole of the anterior 
divisions of the fourth and fifth sacral nerves, and the coccygeal 
nerve. 

It gives off' the following branches: 

Perforating cutaneous .... Second and third sacral. 

Pudendal.Second, third and fourth sacral. 

Visceral.Third and fourth sacral. 

Muscular.Fourth sacral. 

Anococcygeal.Fourth and fifth sacral and coccygeal. 




182 ANATOMY OF THE SENSORY NERVOUS SYSTEM 


The Perforating Cutaneous Nerve (n. clunium inferior medialis) 
supplies the skin over the medial and lower parts of the gluteus 
maximus. 

The Pudendal Nerve (n. pudendus; internal pudic nerve) arises 
from the ventral branches of the second, third and fourth sacral 
nerves, reaches the perineum through a sheath of the obturator 
fascia (Alcock’s canal) and divides into the perineal nerve and 
the dorsal nerve of the penis or clitoris. Before dividing it gives 
off the inferior hemorrhoidal nerve (Plate XIV). 

The Inferior Hemorrhoidal Nerve (n. hcemorrhcidalis inferior) sup¬ 
plies the sphincter ani externus and the skin around the anus. 

The Perineal Nerve ( n . perinei) divides into the posterior scrotal 
(or labial) and muscular branches (Plate XIV). 

The Posterior Scrotal (or Labial) Branches (nn. scrotales (or 
labiates) posteriores; superficial perineal nerves) pierce the fascia 
of the urogenital diaphragm and are distributed to the skin of the 
scrotum in the male and the labium majus in the female. 

The nerve to the bulb, of the muscular branches, supplies the 
mucous membrane of the urethra and the corpus cavernosum 
urethrae. 

The Dorsal Nerve of the Penis (n. dorsalis penis) travels forward 
along the margin of the inferior ramus of the pubis and ends on the 
glans penis and the corpus cavernosum penis. In the female the 
nerve takes the same course. It is very small and supplies the 
clitoris (n. dorsalis clitoridis). 

The Visceral Branches.— The visceral branches arise from the 
third and fourth, and sometimes from the second, sacral nerves, 
to supply the bladder and rectum, and in the female, the vagina. 

The Muscular Branches.— The muscular branches with cutaneous 
filaments derived from the fourth sacral supply the skin between 
the anus and coccyx. 

Anococcygeal Nerves (nn. anococcygei).— These nerves arise 
from the fifth sacral nerve and give filaments to the skin in the 
region of the coccyx. 


THE SYMPATHETIC NERVOUS SYSTEM. 

The sympathetic nervous system supplies all the smooth muscles 
and the various glands of the body as well as the striated muscle 
of the heart, and is the conductor of sensation within the abdomen. 

It is characterized by numerous ganglia and complicated plexuses. 
Efferent sympathetic fibers leave the central nervous system and 
end in sympathetic ganglia, being known as preganglionic fibers. 
From the ganglia, postganglionic fibers arise which carry impulses 


THE SYMPATHETIC NERVOUS SYSTEM 


183 


to the different organs. In addition, afferent or sensory fibers 
connect many of* these structures with the central nervous system. 
The peripheral portion of the sympathetic system is connected 
with the central nervous system by three groups of efferent fibers 
—the cranial, thoracolumbar and sacral. Sympathetic trunks 
extend from the base of the skull to the coccyx, lying in front of 
the bodies of the vertebrae. The ganglia of each trunk are dis¬ 
tinguished as the cervical, thoracic, lumbar and sacral. (Plate XV.) 

The sympathetic nervous system is connected with the spinal 
nerves through the gray and white rami communicantes. 

The Celiac Plexus (solar plexus) is the largest of the three sym¬ 
pathetic plexuses and consists of two large celiac ganglia and their 
nerve network surrounding the celiac artery and the root of the 
superior mesenteric artery behind the stomach and in front of the 
crura of the diaphragm. The greater and lesser splanchnic nerves 
from above join this plexus, which gives off numerous secondary 
plexuses. (Plate XVI.) 











, 









PART II. 





BODY EXCEPT THE AI]DOME 


CHAPTER VII. 

LOCAL ANESTHESIA IN SURGERY OF THE HEAD 

AND FACE. 


THE NERVE SUPPLY OF THE SCALP. 

(Fig. 41, also Plate I.) 

The frontal region is supplied by n. supratrochlearis and n. 
supraorbitalis, both branches of n. ophthalmicus, the first division 
of n. trigeminus (v). 

The lateral region is supplied by (1) ramus zygomaticotemporalis, 
a branch of n. maxillaris, the second division of n. trigeminus; 
(2) rami temporales superficiales of n. mandibularis, the third 
division of n. trigeminus, and (3) ramus temporalis of n. facial. 
These branches are distributed to the superficial temporal fascia 
and the skin. 

The occipital region is supplied by (1) n. auricularis magnus 
(II, III C), which gives off a posterior or mastoid branch; (2) n. 
occipitalis minor (II C ); (3) n. occipitalis major (II C); and (4) 
the third occipital nerve (III C). 

The mastoid region is supplied by the mastoid or posterior ramus 
of n. auricularis magnus (II, III C). 

The ear is supplied by (1) nn. auriculares anteriores to the helix 
and tragus; (2) n. meatus auditorii externi to the external meatus 
and tympanic membrane, both of which are branches of n. mandib¬ 
ularis, the third division of n. trigeminus; (3) ramus auricularis 
(nerve of Arnold), from n. vagus (x) to the back of the auricle and 
external canal; (4) ramus auricularis of n. occipitalis minor (II C) 
to the upper and back part of the auricle; and (5) ramus posterior 
of n. auricularis magnus (II, III C) to the back of the auricle, 
lobule and lower part of the concha. 

While the distribution of these nerves is fairly constant and 



186 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


their position may be learned and quite accurately located by the 
needle when administering local anesthesia they overlap each other 
in the areas which they supply, and in introducing anesthesia the 
greatest satisfaction will result from a complete infiltration block 
across the path of the nerves (Fig. 42), except when only a simple 
incision is to be made. A circumferential injection may be made 
in most cases, infiltrating thoroughly all tissues of the scalp (Figs. 
43 and 44). Accurate knowledge of the nerve supply allows one 
to deposit the solution a little more freely at the points where the 
main branches are known to lie (Fig. 45). 



Fig. 41.—Nerve supply of scalp and face. 1, N. auriculotemporalis of N. mandib- 
ularis; 2, N. auricularis posterior of N. facialis; 3, N. occipitalis major (II C.); 4, 
N. occipitalis minor (II C.); 5, N. auricularis magnus (II, III C.); 6, ramus zygo- 
maticotemporalis of N. maxillaris; 7, N. supratrochlearis of N. ophthalmicus; 8, 
N. supraorbitalis of N. ophthalmicus; 9, N. lacrimalis of N. ophthalmicus; 10, N. 
infratrochlearis of N. ophthalmicus; 11, N. nasalis of N. ophthalmicus; 12, N. infra- 
orbitalis of N. maxillaris; 13, ramus zygomaticofacialis of N. maxillaris; 14, N. 
buccinatorius of N. mandibularis; 15, N. mentalis of N. mandibularis. 

ANESTHESIA OF THE SCALP. 

It is to be noted that the various nerves radiate toward the crown 
and more or less at right angles to a line passing transversely 
around the head just above the eyes and ears and about the occiput. 
These nerves may therefore be interrupted upon this line, pro¬ 
ducing anesthesia in the parts above. The conformation of the 
skull is such that it lends itself ideally both to regional and “ infil- 




















ANESTHESIA OF THE SCALP 


187 



Fig. 42.—Circumferential infiltration block of the scalp. (Horizontal.) 








































188 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


tration block” anesthesia. An adequate line of infiltration across 
the course of the nerves will give anesthesia. One must bear in 
mind that the nerves arising from the various branches overlap 
each other to a considerable degree. One should block a rather 
wide area, and as it is to be considered safe to interrupt all nerves 
leading to the scalp, there is no objection to widely circumscribing 
any area that is to be dealt with (Fig. 43). In case one-half of the 
scalp is to be operated upon the horizontal infiltration with an 
antero-posterior infiltration along the midline (Fig. 44) is indicated. 
The infiltration over the crown effectually interrupts the nerves 



Fig 44.—Circumferential infiltration block of the scalp. (Parietal-frontal.) 


from the opposite side. When operating upon the posterior por¬ 
tion of the scalp the horseshoe-shaped infiltration block is efficient 
(Fig. 43). 


The anesthesia required for operations upon the scalp is the 
same whether or not the skull is to be opened. Intracranial 
injections are unnecessary. In this region the effect produced by 
the adrenalin is most helpful. It reduces the size of the blood¬ 
vessels and thus lessens the tendency toward hemorrhage and 
greatly facilitates operative procedures on the skull. The bone 
itself is insensitive and may be sawed, crushed or cut by means 























ANESTHESIA OF TIIE SCALP 


189 


of the DeVilbiss forceps without painful sensation to the patient, 
the brain tissues themselves are not sensitive excepting near the 
base of the skull, although traction upon the dura at any point 
may cause referred pain. The author has in two instances had 
patients complain of pain when traction upon the dura was made 
in the frontal region. In one case the pain was referred to the 
eves. 



Fig. 45.—Sectional view of infiltration block of the scalp with nerve supply. 1, 
N. supratrochlearis of N. ophthalmicus; 2, N. supraorbitalis of N. ophthalmicus; 
3, N. lacrimalis of N. ophthalmicus; 4, ramus zygomaticotemporalis of N. maxillaris; 
5, N. auriculotemporalis of N. mandibularis; 6, N. occipitalis minor (II 0.); 7, N. 
occipitalis major (II C.) 


Duration.—As the effect of the anesthetic disappears in from 
one and a half to two hours, and a? it may be impossible to com¬ 
plete certain operations in this time, many surgeons feel that some 
other anesthetic should be employed. However, the author has 
not had the least hesitancy in repeating the dose of anesthetic in 
case sensation begins to return before completion of the operation. 
A more decided drawback in his experience has been the fatigue 


I 

































































190 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


of which the patient is apt to complain during a prolonged operation. 
This should be anticipated and guarded against by placing the 
patient in as comfortable a position as possible and by so arrang¬ 
ing the drapes that the patient may shift about slightly from 
time to time and thus reduce the irksomeness to some degree. 
Care should also be taken to supply the patient with water and 
plenty of fresh air. 

In making the infiltration or infiltration block, the method 
described on page 149 (Fig. 31) is followed with the utmost care. 
The initial wheal is made after cautioning the patient, and all 
other intradermal wheals are made from beneath (Fig. 31, B). The 
fluid is injected freely, especially in the regions where the nerve 
trunks are known to lie (Fig. 45). 

Among the special advantages of local anesthesia in work in 
this region are the reduction of hemorrhage, the absence of engorge¬ 
ment of the cerebral vessels and the reduction of shock. 

Excision of New Growths.—For the purpose of excising new 
growths it is well to make the line of anesthesia sufficiently remote 
from the edge of the growth so that radical excision will not be 
interfered with. Every effort should be made to avoid injecting 
tissues in which there is the slightest suspicion of malignancy. 
This work may be carried out after the infiltration block with a 
high degree of satisfaction by carefully following the plan laid 
down on page 149. 

Atheromata.—Atheromata may be excised following an infiltration 
about the base, the needle being introduced repeatedly until it 
reaches the bone. Where large numbers of atheromata are present, 
covering a considerable area, the infiltration block described in 
Figs. 42, 43 and 44 becomes the method of choice. 

SURGERY OF THE SKULL. 

Fractures of the Vault of the Skull.—In all fractures of the vault, 
simple or compound where surgical intervention is considered 
necessary, local anesthesia may be used. In cases in which the 
injury is severe, or the general condition of the patient is bad, 
local anesthesia should be used, even in children. It is well in 
these cases to introduce the anesthetic solution remote from the 
point of injury, as in this manner the possibility of dissemination 
of infection is avoided, and one is less likely to be compelled to 
reinforce the anesthesia on account of the extension of the fracture 
beyond its apparent limits. Children must be restrained while the 
anesthetic is being introduced, but the remonstrance is no greater 
than, and seldom as great as, when general anesthesia is employed. 
Once anesthesia is established the necessary surgical work may 


SURGERY OF TIIE SKULL 


191 


be carried out with despatch, and without greatly increasing the 
depression which is usually already present in these cases. 

Operations upon the Brain.—The blocking of the various areas 
is shown in Figs. 42 to 45, pages 187-189. Under this anesthesia 
the corresponding areas of the skull may be trephined without 
discomfort to the patient. The great reduction in the size of the 
bloodvessels produced by the adrenalin aids materially in exposing 
the skull. In most instances the various methods of preventing 
hemorrhage from the scalp may be dispensed with. While there 
is some hemorrhage from the larger arteries, unless an excessive 
amount of adrenalin is used, this may be easily controlled by the 
application of artery forceps. The skull may be entered by any 
of the numerous methods, with the exception of the mallet and 
gouge, which causes too much discomfort. Sawing of the bone, 
while it does not produce pain, is somewhat annoying to some 
patients. However, it is tolerated in most cases without great 
complaint. Once the brain surface is exposed the operative pro¬ 
cedure is, if anything, less difficult than when general anesthesia 
is employed on account of the absence of engorgement of the vessels. 
(Cases No. 8096 and 11485.) 

Report of Case No. 8096. 

The following case is briefly reported in order to call attention 
to the location of referred pain during an operation: 

L. B., entered the hospital on March 3, 1915. 

Diagnosis: Brain tumor in the left arm and leg center. 

Operation: Decompression, Ligation of varicosities. 

The patient was given a preliminary hypodermic of morphin 
gr. \ and scopolamin gr. T -J~o one hour before the operation, and 
at the beginning of the operation he was given another hypodermic 
of morphin gr. J, as he seemed to be rather nervous. 

100 cc of a 1 per cent novocain-adrenalin solution were injected 
along the line indicated in Fig. 44, page 188. Ten minutes 
after making the infiltration a horseshoe-shaped flap was turned 
down on the right side over the vault of the cranium. The skull 
was opened by means of the Martell drill and a bone flap was 
turned down by the use of a motor saw and dura guard. This 
procedure was entirely painless to the patient, and he did not 
even complain of the grating of the saw. After opening the dura 
the surface of the brain was found to present many dilated veins 
and the tissue appeared to be inflamed. Touching the surface of 
the brain caused the patient to remark that he had sensation in 
the left hand directly. A small portion of the tissue was removed 
and the large vessels ligated. No distinct tumor was found. The 


192 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


dura was adherent mesially and was carefully elevated, after being 
incised. The dura was then partially closed and the flap sutured 
into place, a small catgut drain being inserted. 

The patient made a prompt operative recovery. 

Note .—Traction upon the dura was followed by complaint of 
slight headache and if continued the patient stated that it gave 
him severe pain back of his eyes. Pressure upon the brain sub¬ 
stance with a moist sponge produced sensation in the left hand, 
but no pain. 

As an example of the removal of a growth involving both the 
skull and brain, the following report is given: 



Fig. 46.— Photograph of case No. 11,485. Endothelioma. 


Report of Case No. 11485. 

E. C., aged forty-eight years, entered the hospital, April, 1916. 

This patient was seen in consultation with Dr. Earl R. Hare, 
of Minneapolis, who performed the operation with the writer’s 
assistance. 

The patient had been struck upon the head in childhood. He 
presented a large tumor upon the vertex of the skull, which had 
been of slow growth, but had progressed more rapidly during the 
past year. He complained of headaches, and presented a tumor 
which seemed to involve the skull (see Eig. 46). A radiogram 
showed the growth to be intimately connected with the bone. 

Operation: Excision of tumor on April 19, 1918. 






SURGERY OF THE SKULL 


193 


Anesthesia: 90 cc of a 0.5 per cent novocain-adrenalin solution. 
Circumferential infiltration similar to that described in Figs. 42, 
43 and 44, pages 187 and 188. 

The scalp was reflected back by the means of a crucial incision. 
The cranial cavity was entered by the means of a bone trephine, 
and with the DeA ilbiss forceps a channel was cut around the tumor, 
approximately 2 cm. from its outer border. The longitudinal 
sinus was ligated. As the bone was pried out of its position, it 
carried with it adherent dura from an area 6 cm. in diameter. 
The dura was widely excised and a considerable amount of brain 
tissue, which seemed to be infiltrated, was taken away with the 
growth. The removed dura contained a growth as large as an 
olive. The piece of bone removed was circular, was about 16 cm. 
in diameter and 8 cm. in thickness at its thickest point. A celluloid 
plate was introduced and the wound closed with silkworm gut. 
This patient had no pain that could be directly attributed to the 
operative procedure, although he stated at times that his head 
ached during the operation. He made an uneventful recovery, 
the celluloid plate healing nicely into place. The growth recurred 
at a later period. The pathological report was endothelioma. 

Subtemporal Decompression.—This operation may be performed 
under a direct infiltration or infiltration block. Only 30 to 40 ec 
of solution is necessary to anesthetize the whole area. Under 
this method the operation of decompression becomes almost a 
minor one. We usually puncture the skin at one point only, 
and pass the needle in various directions until the field of operation 
is completely saturated. Case No. 10783. 


Report of Case No. 10783. 

A. B., aged forty-two years, entered the hospital on November 
5, 1917, referred by Dr. H. H. Kimball. x4 diagnosis of advanced 
optic neuritis was made. The patient was seen in consultation 
by Dr. W. A. Jones, who advised subtemporal decompression. 

Anesthesia: 60 cc of a 0.7 per cent novocain-adrenalin solution 
were used. 

A transverse infiltration block was made just above the external 
ear with a vertical limb along the proposed line of incision. The 
skull was opened over an area of 5x7 cm. The dura was opened 
after the ligation of two arterial branches. The opening was 
covered by the temporal muscle. The skin was closed with silk¬ 
worm gut. 

Note .—In this instance the patient remarked at the finish of 
the operation that if this was all there is to such an operation he 
would not mind having one every day. 

This simple procedure is almost a minor operation under local 
anesthesia. 

13 


194 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


THE EAR AND MASTOID. 

Anesthesia of the Tympanic Cavity.— Braun gives the following 
description for obtaining anesthesia of the middle ear and mastoid: 

“In case of destruction of the drum the mucous membrane of 
the tympanic cavity can be anesthetized by dropping into the 
ear a few drops of a 10 to 20 per cent solution of cocain or alypin. 
The complicated shape of this cavity makes it difficult to obtain 
an even distribution of the anesthetic which not infrequently 
interferes with complete anesthesia. Tiefenthal’s injection through 



Fig. 47.—Infiltration block for mastoid operation. 


the unruptured drum has already been mentioned. Neumann 
claims that if fluid be injected beneath the upper wall of the external 
auditory canal, the soft parts will be separated from the bone and 
the fluid must pass under the drum membrane and the mucous 
membrane of the tympanic cavity and in this manner cause both 
the drum and the tympanum to become completely anesthetized.” 

Neumann 1 has described this injection as follows (see Fig. 48): 
“The needle is passed through the cartilage and beneath the 
periosteum of the upper wall of the external auditory canal 
about 0.5 to 1 cm. from the beginning of the bony part. This 


1 Quoted from Braun. 























THE EAR AND MASTOID 


195 


point of injection can be readily determined by moving the 
ear up and down, the cartilaginous portions forming a fold where 
it adjoins the bony part. Another means of distinguishing this 
boundary is the difference in appearance between the cartilaginous 
and the bony part of the canal. The former appears dull, while 
the latter is glossy. After fixing the point for injection, the needle 
is passed in an oblique direction upward until the bony canal is 
felt; the anesthetic solution is then injected under medium pressure. 
It will be necessary to wait about ten minutes before anesthesia 
is complete.” 

With the patient’s head lying on the healthy side, begin by 
instilling a few drops of a 20 per cent alypin or cocain solution with 
the addition of suprarenin into the external auditory canal. Inas¬ 
much as the drum is usually destroyed, the solution itself enters 
the tympanic cavity and can act upon the mucous membrane 
during the subsequent injection. This is not always necessary. 

The opening of the mastoid process and the antrum under local 
anesthesia was attempted before this method was tried for the 
radical operation (Reclus, Schleich, Scheibe, Thies, Alexander, 
Neumann). Inasmuch as these cases usually belong to the acute 
septic type, it is well to consider carefully the advisability of inject¬ 
ing into such an operative field. According to the author’s judg¬ 
ment there must be very definite conditions contraindicating the 
use of general anesthesia before local anesthesia should be attempted. 
At anv rate, this method of anesthesia will be used much more 
frequently in the radical operation than in cases of acute otitis. 
In perforation of phlegmonous suppurations these injections are 
not permissible. 

For the opening of the antrum the Neumann injection is not 
necessary, and the operator should proceed as in the radical opera¬ 
tion. For the simple opening of the mastoid cells, infiltration of 
the soft parts is sufficient. 

Attempts have been made to block the glossopharyngeal nerve 
at the base of the skull by injections through the mouth, but with¬ 
out result. However, Hirschel has apparently succeeded in block¬ 
ing the glossopharyngeal and vagus by means of an injection 
between the condyle of the lower jaw and the mastoid process. 
Whether it will be possible to block the upper branches supplying 
the organs of hearing remains to be seen. 

The author has used the circumferential infiltration block illus¬ 
trated in Fig. 47, and has had equally good results with a simple 
infiltration of the nerves by making a deep infiltration below both 
in front and behind the mastoid. He has also employed the 
technic of Neumann (Fig. 48) and has completed a number of radical 
mastoids under this scheme. 


19G LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


There may possibly be some objection to the infiltration method 
directly over the mastoid process in case infection is already pres¬ 
ent in the soft tissues. However, no ill effects have been found 
to follow this method when carried out in other parts of the body. 
In case there is any question concerning this point, it is a simple 
matter to block the mastoid or posterior ramus of the auricularis 
magnus nerve (II, III C) at its origin between the second and 
third cervical vertebrae. In fact, the infiltration block in this 
region can be used in the place of the circumferential block with 
marked success. Success has not followed attempts at blocking 
the nerve supplying the organs of hearing, which is of course unneces- 
sarv in cases in which only the mastoid cells are to be drained or 
eviscerated. 



Fig. 48.—Anesthetizing the internal ear. (Technic of Neumann.) 


Report of Case No. 11609. 

G. M., a female, aged fifty-four years, entered the hospital on 
July 18, 1918. 

Diagnosis: Subacute mastoiditis. 

Operation: Radical mastoid. 

Anesthesia: Following the technic of Braun (Fig. 47), 40 cc of 
a 1 per cent procain-adrenalin solution were injected around the 
ear. A fine needle was then introduced just posterior to the 
auditory canal after the method of Neumann (Fig. 48) and 2 cc 
of the solution injected here. The radical operation was then 
performed. 

The patient made no complaint throughout the operation, 
except in relation to her position upon the table, which caused 
her to complain of pain in her arm and shoulder. 






















SURGERY OF THE FACE 


197 


Note .— In a number of cases the author has encountered some 
difficulty in obtaining complete anesthesia of the middle ear. 
Curettage of the Eustachian tube cannot usually be accomplished 
without the production of pain, and it is perhaps advisable to use 
topical applications of cocain here. 


THE NERVE SUPPLY OF THE FACE. 

(Plate II and Fig. 41, page 186.) 

The frontal region as mentioned before is supplied by n. supra- 
trochlearis and n. supraorbitalis of the first division of n. trigeminus 
(v). 

The upper eyelids are supplied by (1) n. laerimalis; (2) n. infra- 
trochlearis; (3) n. supratrochlearis; (4) n. supraorbitalis, all of 
which are branches of n. ophthalmicus, the first division of n. tri¬ 
geminus (v). 

The lower eyelids are supplied by n. infratrochlearis. 

The conjunctiva is supplied by (1) n. laerimalis; (2) n. supra- 
trochlearis; (3) n. infratrochlearis, also from the ophthalmic division 
of n. trigeminus and by (4) rami palpebrales inferiores of n. maxil- 
laris, the second division of n. trigeminus (v). 

The nose is supplied by (1) external nasal branch to the ala 
nasi; (2) n. infratrochlearis to the side of the nose; (3) internal 
nasal branches to the septum and lateral wall, all of which are 
branches of n. ophthalmicus, the first division of n. trigeminus, 
and (4) rami nasales externi of n. maxillaris, the second division 
of the same nerve and which supply the septum and lateral wall. 

The cheek is supplied by (1) ramus zygomaticofacialis of the 
second division of n. trigeminus (v), (2) n. buccinatorius of the 
third division of the same nerve, and (3) ramus anterior of n. 
auricularis magnus (1, III C.) 

The upper lip is supplied by rami labiales superiores of n. 
maxillaris, the second division of n. trigeminus. 

The lower lip and chin are supplied by n. mentalis of n. man- 
dibularis, the third division of n. trigeminus (v). 


SURGERY OF THE FACE. 

The blocking of the trigeminus nerve and its various branches 
is extensively described in most of the works upon local anesthesia, 
and in this text the subject will be covered only in a general way, 
referring more particularly to the important operations upon the 
face, and description of methods which have given the author the 
greatest satisfaction. 

Figs. 54 and 56, pages 214 and 215, show the relative locations of 


198 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


the second and third divisions which may be reached by the means of 
various landmarks. The ganglion also may be reached by several 
routes which will be described later. Excision of the superior maxilla 
may be successfully performed after the blocking of the maxillary 
division (Fig. 54). This blocking should be reinforced by a cir¬ 
cumferential subdermal infiltration (Fig. 53), page 214. The inferior 
maxilla may be operated upon after blocking by one of the various 
methods here given. 

Anesthesia.—Blocking of the Trigeminus Nerve (Fifth) (Plate 
II).—Matas must be given credit for being the first to block the 
trigeminus nerve at the base of the skull. Braun gives this sub¬ 
ject in sufficient detail that I feel no better description could be 
given than to quote somewhat extensively from his excellent 
book: 

“The blocking of one or more branches of the trigeminus nerve 
is advisable in nearly all operations upon the face which are not 
confined to the skin or subcutaneous tissue. The blocking can 
be carried out, according to the demands of the operation, either 
at the points of exit of the nerve trunks at the base of the skull in 
the course of one or more of their branches, or intracranial in the 
Gasserian ganglion itself. 

“Anesthesia of the trigeminus nerve at the base of the skull 
was first performed by Matas in the foramen rotundum. Boeken- 
heimer, at the suggestion of Payrs, likewise carried out this pro¬ 
cedure. The first contribution and description of several operations 
upon the face was published by Peuckert. The method has since 
been materially improved following the introduction by Schloesser 
of alcohol injections in the treatment of trigeminal neuralgia and 
by the work of Haertel. We are indebted to Offerhaus for his 
important communications in reference to the technic of injection 
of the third branch of this nerve. He devised this method inde¬ 
pendently, following his experiments with alcohol injections. He 
likewise used anesthetic substances to render operations painless. 

“For the central trigeminus injection the long, thin needles 
Nos. 5 and 0 should be used. The needle-holder will be found very 
helpful with needles of this length." 

The Ophthalmic Nerve (Plate II). —“The peripheral branches on 
the forehead are easily reached by a subcutaneous injection of 5 
to 10 cc of a 1 per cent novocain-suprarenin solution made trans¬ 
versely above the eyebrows. (See Figs. 41 and 45, pages 186 and 
189.) The area of this anesthetic field is quite variable and the 
principle as previously laid down should always be followed, that 
in operations upon the forehead and scalp large operative fields 
should always be circuminjected. 

“The trunk of the ophthalmic nerve cannot be directly injected, 


SURGERY OF THE FACE 


199 


inasmuch as it usually divides into its branches the lacrimal, 
frontal and nasociliary before entering the orbit. The nasociliary 
passes through the annulus tendineus into the apex of the orbit 
and innervates the eye. Its two branches, the ethmoidal nerves, 
leave the apex of the orbit and pass into the anterior and posterior 
ethmoid foramen. The frontal and lacrimal lie entirely outside 
of the apex of the orbital wall and like the ethmoidal nerves are 
inaccessible to injections in the posterior portion of the orbit. 

“ Deep Blocking. —The walls of that portion of the orbit which 
are straight and not concave are particularly suitable for injection, 
and serve as a guide for the needle to the orbital apex beyond the 
muscular covering, keeping the needle in constant contact with 
the bone. These conditions are found along the lateral walls and 
the upper portion of the median wall of the orbit. In other places 
where the point of the needle cannot be held in contact with the 
bone there is always danger of injury to the eyeball. The use of 
curved needles cannot be recommended, as the exact location of 
the point is never known. The lateral point of injection lies 
immediately above the outer canthus of the eye. The needle is 
passed with its point constantly in contact with the bone to a depth 
of 4.5 to 5 cm. and here crosses the superior orbital fissure. The 
point encounters the distal border of this fissure in the upper wall 
of the orbit which prevents its further introduction. About 2.5 
cc of a 2 per cent novocain-suprarenin solution is injected in the 
neighborhood of the superior orbital fissure. 

“The point of entrance for the median orbital injection lies one 
finger-breadth above the inner canthus of the eye. The needle is 
again passed to a depth of 4 to 5 cc, keeping it at all times in con¬ 
tact with the bone, and the same quantity of solution injected at 
this point. 

“The lateral orbital injection blocks the frontal and lacrimal 
nerves which is necessary in operations in the orbit and frontal 
sinuses. The frontal nerve and its branches can likewise be blocked 
farther forward in the orbit by injections made above the bulb. 

“ The median orbital injection blocks the anterior and posterior 
ethmoidal nerves which supply the mucous membrane of the 
cribriform plate of the ethmoid, frontal and sphenoid sinuses. 
Besides these parts the anterior ethmoidal nerve supplies a portion 
of the nasal mucous membrane and then passing from the nose at 
the junction of the cartilaginous and bony part is distributed in 
the skin of the tip of the nose and its surroundings. The median 
orbital injection is, therefore, necessary in operations upon the 
nasal cavities and other accessory sinuses. 

“After the injection a mild, transient protrusion of the bulb 
and edema of the upper lids occurs. The injections into the orbit 


200 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 



insensitive by means of a wheal. The injected fluid is entirely 
outside of the muscular boundaries of the orbit, for which reason 
the sensory nerves of the bulb, ciliary nerves, ciliary ganglion and 
the optic nerve are not, as a rule, affected. If the nerves just 
mentioned are to be anesthetized the solution must be injected 
behind the bulb and within the muscle boundaries of the orbit. 

“ Serious disturbances following orbital injections and injury 
to the bulb are practically impossible. Small hematomata occur 
occasionally in the orbital fat, particularly following the lateral 
injections, but are of no consequence. Krefel observed amaurosis 
lasting ten minutes following an injection into the orbit. It is 
possible that this occurrence may have been more frequently 
observed than reports indicate, inasmuch as the optic nerve can 
be affected by the anesthetic as well as by the anemia consequent 
upon the use of suprarenin. Another case of temporary amaurosis 
following local anesthesia for empyema of the frontal sinuses has 
been reported by Jassenetzky. This condition occurred on the 
day following the operation and was due to an inflammatory 
edema of the orbit, and inasmuch as the case was a septic one it is 
very questionable whether the injection had anything to do with 
the inflammatory symptom.” 

The Maxillary Nerve (Plate II). — “The peripheral branches of 
this nerve are the infraorbital, superior, posterior and median 
alveolar nerves. The latter penetrate the upper jaw posteriorly 
to the maxillary tubercle. Both of these branches are readily 
blocked. 

“The infraorbital foramen can be reached by passing a needle 
beneath the upper lip where the submucosa is reflected from the 
alveolar process along the anterior surface of the upper jaw to the 
point of emergence of this nerve, or, better, by passing the needle 
from without directly into the infraorbital foramen. The injection 
after either method is made with 2 cc of a 2 per cent novocain- 
suprarenin solution. When passing the needle from without into 
the infraorbital foramen, a fine one should be used and inserted 
just beneath the lower orbital border and passed until it touches 
the bone, where a small quantity of a 2 per cent novocain-suprarenin 
solution is injected, following which the opening of the canal is 
sought with the needle. The injection of 1 cc of a 2 per cent 
solution is sufficient for blocking the nerve. The following 
structures are anesthetized: The lower eyelids, the upper lip, the 
larger part of the alse of the nose (skin and mucous membrane), 
a part of the skin and mucous membrane of the cheek, the labial 
mucous membrane, the anterior portion of the upper alveolar 
process and its periosteum, the anterior wall of the upper jaw and 
the pulp of the central and lateral incisor teeth.” 


SURGERY OF THE FACE 


201 


Matas’s first method of reaching the maxillary nerve in the 
foramen rotundum was by passing the needle below the lower 
border of the zygoma and along the surface of the upper jaw through 
the pterygopalatine fossa. Schloesser used this route for alcohol 
injections. In order to reach the nerve from this position the 
needle is introduced at a point behind the lowest palpable angle 
of the malar bone. From here it passes inward and upward through 
the masseter muscle and along the posterior surface of the superior 
maxillary bone. The nerves lie approximately 5 or 6 cm. from the 
surface. One should depend, however, upon the paresthesia or 
pain produced by contact of the needle with the nerve tissue. The 
author has used from 5 to 10 cc of 1 per cent novocain-adrenalin 
solution. Matas and Payr reached the foramen rotundum by pass¬ 
ing the needle directly through the orbit. Braun gives the follow¬ 
ing directions. 

“A point is chosen for injection where the lower edge of the 
orbit meets the outer edge. The needle is passed into the orbit 
at this point in an almost vertical direction and kept in constant 
contact with the bone forming the floor of the cavity. The inferior 
orbital fissure is now sought and recognized by the needle passing 
into it. As soon as this happens, the end of the needle is lowered 
so that it will assume a horizontal position, which prevents it 
passing into the infratemporal fossa or into the orbital fat, which 
is also to be avoided. A false passage will be recognized by the 
absence of resistance to the progress of the needle. This resist¬ 
ance always occurs when the proper direction is taken and 
causes immediate radiation of paresthetic sensations which fre¬ 
quently require the injection of a few drops of the novocain-supra- 
renin solution. At a depth of about 5 cm. the needle will be in 
the foramen rotundum and there encounter the bony obstruction 
at the base of the skull. After a successful injection, anesthesia 
will immediately occur in the entire area of distribution of the 
maxillary nerve. Injections which have been only partially suc¬ 
cessful require ten to twenty minutes before the full effect is 
obtained. After these injections the corresponding half of the 
face becomes anemic in consequence of the action of the suprarenin 
on the end branches of the internal maxillary artery. 

“One of the secondary effects which may follow injection into 
the pterygopalatine fossa, besides small hematomata on the posterior 
surface of the upper jaw, is paralysis of the muscles of the eye, 
particularly the oculomotor nerve, due to the needle occasionally 
passing through the inferior orbital fissure into the orbit. This 
paralysis disappears with the return of sensation. Although the 
dangers following injections for purposes of anesthesia are slight 
one must be particularly careful with alcohol injections. Alcohol 


202 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


must never be introduced until after the nerve has been blocked 
with anesthetics in order to prevent these secondary effects on the 
muscles of the eye. 

“Injection through the orbit does not cause paralysis of the 
muscles of the eye, inasmuch as the needle passes entirely out of 
the orbit, for which reason alcohol injections can be made much 
more safely by this route. Hematomata on the floor of the orbit 
and in the upper lid occasionally occur after orbital injections.” 


Report of Case No. 13960. 

This case illustrates the block of the maxillary division of the 
fifth nerve according to the method of Braun: 

L. M., female, aged twenty-four years, entered the hospital in 
August, 1920. 

Diagnosis: Right maxillary sinusitis. 

Operation: Denker’s operation with drainage. 

Anesthesia: Maxillary nerve block with 22 cc 1 per cent 
novocain-adrenalin. 

Anesthesia Technic: Blocking of the maxillary division of the 
right trigeminus with novocain-adrenalin solution. The needle 
was introduced at a point 2 cm. posterior to the external canthus 
of the eye just below the zygoma. Paresthesia was felt in the 
right side of the face and 2 cc of a 2 per cent novocain-adrenalin 
solution was injected. Within a minute towel pins could be placed 
upon the lip. The lip was retracted and the sinus opened, curetted 
and drained without the production of pain. 

This patient developed a slight exophthalmos of the right eye 
directly after the injection. The right pupil dilated and there 
was disturbance of vision for two or three hours, when the con¬ 
dition disappeared. 

The Mandibular Nerve.—The mandibular nerve may best be ap¬ 
proached at a point on the inner surface of the lower jaw in the region 
of the lingula (Figs. 57 and 58, page 216)* It may also be blocked 
in the foramen ovale as it leaves the skull (Fig. 56, page 215). 
Halstead was perhaps the first one to block the nerve inside the 
oral cavity. Braun calls the depression upon the ramus of the 
inferior maxilla in which the nerve lies the “trigonum retromolare.” 
For the injection of this nerve within the mouth the use of long 
needles is advisable. The direction of the needle should be from 
the region of the canine tooth on the opposite side diagonally 
across the mouth, the needle lying in a plane parallel to the biting 
surface of the teeth. A wheal is made in the mucous membrane 
over the position of the nerve and the needle is advanced until 
it reaches the bone. It then follows the bone backward until it 


SURGERY OF THE FACE 


203 


is felt to drop over the lip of bone lying directly in front of the 
trigonum retromolare (Fig. 58, page 216), 5 to 10 cc of a 1 per cent 
novocain-adrenalin solution will give anesthesia in the corre¬ 
sponding half of the lower jaw and in approximately one-half of 
the tongue. The anterior branches of the nerves may be 
anesthetized by entering the needle into the mental foramen which 
lies in a line drawn across the supraorbital and infraorbital foramina 
and is generally below the space occupied by the first and second 
bicuspid teeth. 

Braun states: “The shortest and most certain way of reaching 

CJ 

the foramen ovale is from without, the needle being passed just 
below the border of the zygoma, and if the directions of Offerhaus 
are followed there is almost certaintv that the anesthetic solution 

t/ 

will not only be injected around the foramen ovale but directly 
into the trunk of the mandibular nerve where it emerges from the 

skull. 

“Offerhaus found, after accurate measurement of 50 skulls, 
that the line connecting the articular tubercle lies just in front 
of the maxillary articulation, and intercepts the two points which 
are just a few millimeters below and, as a rule, the same distance 
in front of both foramen ovale. 

“ Inasmuch as the mandibular nerve after its emergence from 
the skull passes forward and downward, the intertubercular line 
crosses these nerve trunks exactly at the foramen ovale. 

“Offerhaus also noted that the distance between the alveolar 
processes of the maxilla measured from the outside behind the 
last molar tooth corresponds within a few millimeters to the dis¬ 
tance between both foramen ovale, so that if the width of the 
alveolar processes is subtracted from the length of the intertuber¬ 
cular line, and this result divided by 2, the result will give within 
a few millimeters the distance of the foramina from the articular 
tubercle of the same side. According to the measurements of Offer¬ 
haus the minimum distance would be 3.6 cm. and the maximum 4.7 
cm., the usual distance being 3.7 to 4.3 cm. In order to find the 
direction and length of the intertubercular line in the living patient, 
Offerhaus constructed an apparatus, the points of which if placed 
on both articular tubercles, the direction of the intertubercular 
line is indicated by the adjustable points of the instrument and the 
distance between both tubercles is measured on the sliding scale. 

“The injection is performed in the following manner: On the 
side where the injection is to be made the articular tubercle is 
marked by a wheal and the point on the opposite side marked with 
a blue pencil. The distance between the outer side of the alveolar 
process of the maxilla behind the last molar teeth is measured with 
ordinary compasses and with Offerhaus compasses the length of 


204 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


the intertubercular line is determined. For example, if these 
distances are 5 and 14 cm. the points will be 4.5 cm. distant 
from the point of insertion of the needle. A small cork placed on 
the needle, about 1 cm. farther than the above-mentioned length, 
will show how far the needle should be inserted and also allow for 
additional play. The needle, however, should never penetrate 
deeper than this. The Offerhaus compasses are again placed 
upon the head and the needle passed into the tissues in the direction 
indicated by the points on the compasses. Exactly at the point 
determined the patient will complain of radiating pains in the 
lower jaw. As a rule, the resistance of the thick nerve trunk can 
be felt at the needle-point, and at times the needle can be pushed 
into this trunk. After the needle is in the nerve trunk a very 
few drops of a 2 per cent novocain-suprarenin solution are suf¬ 
ficient; if near the nerve trunk 5 cc of this same solution are injected. 
The blocking of the nerve often occurs instantaneously, but never 
requires more than five to ten minutes.” 

“The following description of the injection of the foramen ovale 
is somewhat simpler than the above. The point of entrance for 
the needle is marked just below the middle of the zygoma and the 
needle is inserted in an almost transverse direction. This direction 
is easily determined by holding a skull with the direction marked 
by a sound alongside the head of the patient. At a depth of 4 to 
5 cm. the end of the needle touches the bone, the pterygoid pro¬ 
cess. In this injection the needle is about 1 cm. distant from the 
foramen ovale. This distance is marked on the needle with the 
movable piece of cork. The needle is then withdrawn as far as 
the subcutaneous connective tissue and is passed back again at 
a slight angle to the same depth and possibly a few millimeters 
more. The characteristic radiating pains will then occur. 

“This last method can be further simplified by computing the 
depth at which the foramen ovale is found. As a rule the author 
combines both methods in directing the needle, but passes it some¬ 
what more anteriorly than Offerhaus, feeling for the base of the 
pterygoid process. Then, as already mentioned, the needle is 
directed slightly backward and inserted 0.5 to 1 cm. more than 
the previously computed distance. Hematomata or other secondary 
effects never follow injections into the foramen ovale when made 
from without. 

“The methods described by Ostwalt and Schloesser for the injec¬ 
tion of alcohol into the foramen ovale cannot be compared with the 
method just described, for certainty and freedom from danger. In 
this method Ostwalt passes a long angular needle through the wide- 
open mouth behind the last molar tooth through the externa] 


SURGERY OF THE FACE 


205 


pterygoid muscle and, by using the external lamina of the ptery¬ 
goid process as a guide, reaches the foramen ovale. Schloesser 
for like purposes locates with the finger in the mouth the lower 
end of the wing of the sphenoid, passing a long straight needle 
through the cheek, coming out just below the finger in the mouth, 
and then through the mucous membrane and under the finger 
toward the wing of the sphenoid above, until the resistance of the 
base of the skull is felt. The needle point must now lie a few 
millimeters in front of the foramen ovale.” 


“The exploratory puncture and injection of the Gasserian 
ganglion 1 through the oral cavity as described by Ostwalt and 
Offerhaus has very little in its favor, as is admitted by Offerhaus. 
Apart from the almost impossible asepsis, the needle approaches 
the flattened ganglion too acutely and does not have sufficient 
‘ play/ so that it promptly punctures the upper dural sheath of the 
cavum meckeli.” 

“Haertel has described a very exact method for directing the 
needle in puncture of the Gasserian ganglion, which is in part 
similar to Schloesser’s. His method is likewise of great value in 
the interruption of the third branch of the trigeminus.” 

What would appear to be an excellent plan for reaching the 
second and third divisions of the trigeminal nerve and one with 
which the author has had no experience is described by Francis 
C. Grant 2 of Philadelphia. Dr. Grant states in part: 

“Any attempt to reach a nerve trunk lying deep beneath the 
skin, and emerging from bony orifices in the skull, requires definite 
landmarks and angles as guides to the approach. In this clinic 
there has recently been developed an instrument called a zygo- 
meter (see Figs. 49 and 50) which helps in great measure to deter¬ 
mine accurately the point on the face at which the needle should 
be introduced to reach a particular nerve trunk. Using this 
instrument to standardize the points of insertion of the needle 
through the skin, we have worked out, in a series of cases in the 
dissecting room, the angles in the horizontal and vertical plane 
through which the needle must pass from this fixed surface point 
to enter the nerve trunk. In the case of the second division of 
the trigeminus, which is the more difficult of the two branches to 
inject, three points of approach were used, and the angles taken 
by the needle in penetrating the nerve were ascertained. For 
the third division, owing to the relative ease of injecting it, only 


1 Haertel, F.: Gasserian Ganglion Injection through Oral Cavity, Arch. f. klin. 
Chir., 1912, 100 , 199. 

2 Anatomic Study of Injection of Second and Third Divisions of Trigeminal Nerve 
(from the Clinic of Dr. C. H. Frazier, University Hosp., Philadelphia), Jour. Am. 
Med. Assn., 1922, 78 , 794. 


20G LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


one fixed point was employed, and its corresponding angles were 
determined.” 

The calvarium was removed from every specimen in order that 
the point of the needle be accurately ascertained. The approach 
for the second branch is subzygomatic, 3.5 cc being injected anterior 
to the ear. In 162 attempts it was impossible to reach the second 
branch of the nerve in only 4 instances. In 19 cases it was necessary 
to open the lower jaw to avoid impinging upon the coronoid pro¬ 
cess. In 13 of the 19 cases this occurred on both sides. 



Fig. 49.—Injecting third division of fifth nerve from 2 cm. mark: Method of measur¬ 
ing angle (110 degrees) in vertical plane with protractor. (Grant.) 


Grant further states: 

“ .In spite of these efforts to 

establish a uniform procedure it was found that in only 53 of the 
81 cases in which both sides were measured did the angles in corre¬ 
sponding planes on right and left agree within a margin of error 
of 5 degrees. In the other 28 cases, 21 varied within 10 degree 
and the remaining 7 showed a discrepancy of from 10 to 20 degrees. 
The error seemed as great in one plane as in the other. This 
variation is an evidence of how markedly the two sides of the 
skull may differ. The depth at which the nerve was reached varied 
between 5 and 5.5 cm. from the surface. It is believed that a 

V 









SURGERY OF THE FACE 


207 


penetration greater than 5.75 cm. would be attended with con¬ 
siderable risk of damaging important structures through the passage 
of the needle point into the posterior part of the orbit or nose. 

“To inject the supramaxillary nerve by this method the needle 
is inserted at the 3.5 cm. mark on the lower border of the zygo- 
meter. The point of the needle should be directed inward at an 
angle of 98.5 degrees in the horizontal plane and 115 degrees in 
the vertical plane, as described. The needle passes below the 



Fig. 50.—Injecting third division of fifth nerve from 2 cm. mark: Method of measur¬ 
ing angle (90 degrees) with protractor in the horizontal plane. (Grant.) 


zygoma. At this point it may at once be obstructed by the coronoid 
process of the mandible. If so, the jaw should be opened, which 
will allow the needle to pass. The vertical angle should now be 
increased a trifle, thus deflecting the needle-point slightly above 
the exact point at which the nerve is to be sought. At about 
4.5 cm. depth a bony process will be met which is the pterygoid 
plate. Next the vertical angle should be decreased slightly by 
lowering the needle point. Then the point is slid forward over 
the upper anterior edge of the pterygoid plate into the spheno¬ 
maxillary fissure, where, at a depth of from 5 to 5.5 cm., the nerve 
is reached. The sensation of sliding forward into a cleft over 
the edge of the pterygoid plate is very striking and makes the 









208 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


experienced operator feel sure of a successful injection. In the 
4 cases of a series in which it was impossible to transfix the nerve 
by this route, the interference seemed to be due to an anterior 
development of the pterygoid plate, which prevented the needle 
point from passing anteriorly to it with any chance of hitting 
the nerve. The dangers in the use of this method are twofold: 
If the needle point is held too high and inserted more than 5.5 
cm., it is possible to enter the orbit through the posterior part of 
the sphenomaxillary fissure; if held too low and advanced too far, 
the needle tip will pierce the thin, bony walls of the nasal cavity 
or pass through the sphenopalatine foramen into the posterior 
nares. 

“ Subzygomatic Injection of the Maxillary Division from Five- 
centimeter Mark.— The second approach to the superior maxillary 
division of the trigeminus is through a point 5 cm. anterior to the 
external auditory meatus. The zygometer is in the same position 
as in the previous method, and the angles the needle shaft forms 
with the skin are measured in the same fashion as from above 
downward and from before backward. In a series of 120 injections 
on 60 cadavers the average for the horizontal angle was 87 degrees 
and for the vertical angle, 138 degrees. There was no variation 
between the angles at which the nerve was reached on the right 
and left side of more than 10 degrees. 55 of the 60 cases showed a 
variation between the two sides of less than 5 degrees. In every 
case it was possible to reach the nerve. The point of entrance of 
the needle is so far forward that the instrument must be passed 
below the malar, which accounts for the larger vertical angle. 
In general, this is the route used in the intra-oral method advocated 
by Sehlosser 1 and Ostwald, 2 this method being an extra-oral modi¬ 
fication of their technic. 

“Suprazygomatic Injection of Maxillary Division.— The third 
avenue of approach that we studied is suprazygomatic. With 
the zygometer in the standard position the superior border of the 
zygoma and the temporal border of the malar bone are outlined 
by palpation. The apex of the angle formed by the junction of 
these two bones is approximately 3.5 cm. anteriorly on the base 
line of the zygometer. Using this point for the insertion of our 
needle in a series of 60 injections in 32 cases, the average angle 
in the horizontal plane is 100 degrees and in the vertical plane, 
87. In 2 cases on the right and the left side in the same case it 
was found impossible to reach the nerve trunk by this approach. 
In 23 of the 30 cases the right and the left angles agreed within 5 
degrees. The other 7 cases right and left conformed within 10 
degrees. 

1 Munchen. med. Wchnschr., April 30, 1897, 

2 Presse med., December 16, 1905- 


SURGERY OF THE FACE 


209 


“The needle is inserted above the zygoma at the 3.5 cm. mark 
almost perpendicularly in the vertical and slightly forward in the 
horizontal plane. The point impinges first on the posterior wall 
of the maxillary antrum and is carried along this wall and slightly 
downward to pass under the upper anterior curved edge of the 
pterygoid plate. By holding close to these two bony landmarks, 
the nerve is reached at about 4.5 cm. from the surface. If the 
needle be inserted too far the lateral wall of the nose may be 
pierced, although this is not a serious mishap. The needle is at 
all times well below the level of the optic nerve and anterior to 
the larger bloodvessels. This, therefore, is a safe procedure, and 
the angles are fairly constant. But from the number of trials 
required before the nerve could be reached in many cases, and with 
total failure in 2 out of 32, we fear that clinically this method may 
not be as satisfactory as was hoped. 

“ Injection of the Mandibular Division .—For injection of the 
mandibular division of the trigeminal nerve, only one approach 
was considered. Injection of this branch is relatively so simple 
and satisfactory that no other method is needed. With the zygo- 
meter in the standard position, the 2 cm. mark on the lower bar 
was selected. This corresponds approximately to the point of 
election described by Levy and Baudouin. Through this point, 
162 injections were made on 81 cadavers. The nerve was easily 
reached in every case. The horizontal angle averaged 91 degrees, 
and the vertical angle 108 degrees. In 52 of the 81 cases the angles 
for injection on the left and right corresponded within 5 degrees, 
in 26 within 10 degrees; in 3 cases, the variation was more than 
10 degrees. In the 3.5 cm. approach to the second division, the 
angles measured in 53 of the 81 cases were equal within 5 degrees 
right and left. In 40 of these 53 cases in which the second division 
measurements were in accord on either side, the third division 
measurements were also closely similar. These figures only go 
to prove the variability of structures on the opposite sides of the 
same skull. 

“The needle is inserted below the zygoma opposite the 2 cm. 
mark on the lower bar. The direction is perpendicular to the 
skin in the horizontal plane, and a little upward in the vertical 
plane. Once the zygoma is passed, the needle point should be 
deflected slightly upward to strike the floor of the middle fossa. 
This bone is followed backward, bearing at the same time some¬ 
what forward to avoid the middle meningeal artery, which passes 
through the foramen spinosum just posterior to the foramen ovale 
until, at a depth of 4.5 cm., the nerve is reached. By thus keep¬ 
ing the needle point high, it was possible in every case studied to 
inject the entire ganglion through the foramen ovale if such a 
14 


210 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


procedure should be deemed necessary. If it does not seem desir¬ 
able to affect the whole ganglion but only the third division, the 
needle point should be held a trifle lower. The nerve will then 
be pierced somewhat beyond its exit through the foramen. If the 
direction of the needle is accurate, the nerve will always be reached 
within 5 cm. of the surface. The needle point should never be 
allowed to penetrate to a greater distance than 5 cm. 


Summary. 


“ 1. In 162 subzygomatic injections of the supramaxillary division 
of the fifth nerve from the 3.5 cm. mark: 

“ (a) The average angle was 98.5 degrees in the horizontal 
and 115 degrees in the vertical plane. 

“ ( b ) In 65 per cent of injections, the angles for the right 
and left sides corresponded within a margin of error 
of 5 degrees. 

“ (c) In 25 per cent of the cases there was a variation of 
10 degrees in the corresponding angles on the two 
sides. 

“ (d) In 10 per cent of the cases the variation was between 
10 and 20 degrees in the corresponding angles on 
the right and left. 

“ ( e ) The percentage of failures to reach the nerve was 4.7. 

“2. In 128 subzygomatic injections from the 5 cm. mark: 

“ (a) The average horizontal angle was 87 degrees and the 
vertical angle, 138 degrees. 

“ ( b ) In 91 per cent of the subjects, the corresponding angles 
on the right and left were equal within a margin 
of error of 5 degrees. 

“ (c) In the remaining 9 per cent, the variation was 10 
degrees or less. 


“ (d) There were no failures to reach the nerve by this route. 
“3. In 62 suprazygomatic injections from the 3.5 cm. mark on 
thirty-two subjects: 

(а) The average vertical angle was 87 degrees, and the 
horizontal angle, 100 degrees. 

(б) In 72 per cent of the cases, the corresponding angles 
on the right and the left agreed within 5 degrees. 

(c) In 22 per cent of the cases the difference in the corre¬ 
sponding angle, right and left, was 10 degrees. 

( d) In 6 per cent of the cases it was impossible to reach 
the nerve by this route. 

4. It was always possible to reach the nerve in every case, 


u 


u 


(i 


(( 


SURGERY OF THE FACE 


211 


u 




(( 


(( 


right and left, by one of these three methods. In no case were all 
successful. 

o. In 162 subzygoma tic injections of the mandibular division 
of the trigeminus from the 2 cm. mark: 

“ ( a ) The average vertical angle was 108 degrees, and the 
horizontal angle, 91 degrees. 

(b) In 62.2 per cent the corresponding angles on the right 
and left agreed within 5 degrees. 

(c) In 32.1 per cent the angles varied within 10 degrees. 

(d) In 3.7 per cent the angles varied more than 10 degrees. 

(e) In 75.4 per cent of the cases in which the corresponding 

angles of injection by this route agreed within 5 
degrees, the angles of injection for the supramaxillary 
division from the 3.5 cm. mark by the subzygo- 
matic route also varied less than 5 degrees. 

“ (j) There were no failures to reach the mandibular division 
by this route.” 

The V an Allen method 1 of injecting the Gasserian ganglion is 
as follows: 

“The method of approach is by way of the orbit, the pathway 
is the median wall of the orbit and the portal of entrance is the 
sphenoidal fissure. The needle is guided by touch until its prog¬ 
ress is obstructed by the bony fossa lodging the ganglion. A 
Patrick cranial needle 10 cm. long and 1.5 mm. in diameter with 
a snug stylet is used and the needle point is ground back 3 or 4 
mm. so that the stylet acts as a blunt probe leaving the sharp 
pointed needle when the stylet is withdrawn. (Figs. 51 and 52.) 

“The patient is placed in the dorsal position and the upper and 
inner angle and median wall of the orbit are infiltrated with 1 per 
cent novocain-adrenalin (see Fig. 51). An incision 3 or 4 mm. 
long is made just below the superior oblique muscle, using the 
pulley as a guide and extending it to the orbital plate. The peri¬ 
osteum is loosened with the scalpel point for 0.5 cm. Then the 
needle with stylet in place is inserted into the slit and passed back¬ 
ward and toward the mouth until the median wall of the orbit is 
felt to slope away to the floor. Using the upper and inner angle 
of the orbit as a fulcrum, the junction of the wall and floor is fol¬ 
lowed until a bony obstruction is reached, which is the lower margin 
of the sphenoidal fissure. The needle point is lifted over the 
obstruction and passed into the fissure (Fig. 52). The shaft of the 
needle is held firmly against the inner angle of the orbit and the 
tip lodged within the lower extremity of the sphenoidal fissure, 
the stylet is withdrawn and the needle driven straight through 


1 Transorbital Puncture of the Gasserian Ganglion, Annals of Surgery, 1921, 74 , 525. 


212 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


the middle cranial fossa until bony resistance is felt when it will 
be in the ganglion as evidenced by facial pain. The depth varies 
from 8.5 to 10 cm. 



Fig. 51. —A. Van Allen’s needle used in puncture of the Gasserian ganglion 
(greatly enlarged): B, right, eye illustrates the direction taken in inserting the needle; 
C, right eye illustrates position of needle when ganglion is reached. 


“The dangers of this method are: (1) rupture of the median 
wall of the orbit; (2) puncture of the cavernous sinus with throm¬ 
bosis but not hemorrhage; and (3) puncture of the silent area of 
the brain without ill effects. If the first attempt fails, dis¬ 
continue the method for this case. 






SURGERY OF THE FACE 


213 


“Eighty per cent of the 5 cases reported were successful.” 

1 he most extensive operations which one is called upon to per¬ 
form in this region are excisions for malignant disease. The fore¬ 
going pages furnish excellent descriptions of the various methods 
of producing anesthesia for operations upon the face. 



Fig. 52.—Anterior view of the right orbit indicating first portion of needle path. 

(Van Allen.) 


In making excisions of the superior maxilla, the author has made 
a subdermal infiltration as illustrated in Fig. 53, before blocking 
the maxillary nerve (Fig. 53, A). 

In making the maxillary nerve block an infiltration along the 
course of the nerve as shown in Fig. 54 will suffice. 

In operating upon the inferior maxilla, the subdermal infiltration 






Fig. 53.—Anesthesia for excision of superior maxilla, subdermal infiltration and 

A. block of the maxillary branch. 



Fig. 54.—Sectional view of Fig. 53. 1, N. ophthalmicus; 2, N. maxillaris; 

3, ganglion semilunare (Gasseri); 4, N. mandibularis; 5, N. lingualis. 


































Fig. 55. —Anesthesia for excision of inferior maxilla. Subdermal infiltration for 
block dissection of neck. A, block of the cervical plexus; B, block of the mandibular 
branch, n. trigeminus. 


1 



Fig. 56. —Sectional view of Fig. 55. A, block of cervical plexus; B, block of 
the mandibular nerve. 1, N. ophthalmicus; 2, N. maxillaris; 3, ganglion semi- 
lunare (Gasseri); 4, N. mandibularis; 5, N, lingualis. 































Fig. 58. —Sectional view of 
micus; 3, N. buccinatorius; 4, 
6, N. alveolaris inferior. 


Fig. 57. 1, A. maxillaris interna; 2, N. ophthal- 

ganglion semilunare (Gasseri); 5, N. mandibularis; 



































































































SURGERY OF THE FACE 


217 


also precedes the blocking of the mandibular nerve as shown in 
bigs. 55, B and 56, B. In case the dissection of the glands of the 
neck is to be carried out the blocking of the cervical nerves (Figs. 
55, A and 56, A) should be made. (See Fig. 68, page 231.) 

The most simple method of reaching the mandibular branch is 
the transoral route (Figs. 57 and 58). 

Cases Nos. 11349, 14106 and 15752 are respectively examples 
of carcinoma of the alveolar process of the inferior maxilla and the 
lip and Case No. 14169 is one of fracture of both maxillae and skull, 
all of which were treated surgically under local infiltration. 


Report of Case No. 11349. 

K. L., aged fifty-six years, entered the hospital on June 4, 1918. 
Diagnosis: Carcinoma of the alveolar process of the right inferior 
maxilla. 

After preliminary cleansing of the teeth the patient was operated 
upon in two stages. 

First Operation: Preliminary excision of the glands of the neck. 

Second Operation: Resection of the inferior maxilla. 

• Anesthesia: June 5, the patient was given a hypodermic of 
morphin J, scopolamin ^Iro- The classical infiltration block of 
the cervical nerves (Fig. 68, page 231) was made. In addition a 
subdermal infiltration (Fig. 55, page 215) was made, the upper line 
extending well upon the cheek. 

The incision was made parallel to and above the clavicle and 
continued upward along the anterior border of the trapezius. 
A flap was dissected forward, the sternocleidomastoid muscle 
divided low down and a block dissection of the neck was made, the 
parotid gland being removed. Several enlarged glands in the 
neck were identified and removed. Microscopical examination of 
these showed them to be benign. The wound was closed with 
drainage. The patient left the hospital in a week without sub¬ 
mitting to the radical operation. After a delay of another week 
he returned and complete excision of the growth was attempted. 

Second Operation: June 22, 1918. 

Anesthesia: The patient was once more given a preliminary 
hypodermic and, as it was impossible to reach the mandibular 
branch from within the mouth, direct infiltration was depended 
upon. Subdermal infiltration from the lobe of the ear to the mid¬ 
line in front was made. This infiltration was carried below the 
angle of the jaw and then deeply into the neck at the base of the 
tongue; 90 cc of a 0.6 of 1 per cent novocain-adrenalin solution 
were used. 

The lower jaw was divided at the mental foramen and dislocated 


218 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


behind. A portion of the tongue and the pillars of the fossae of 
the corresponding side were removed, the cautery being used in 
dividing the soft tissues. The patient made an uneventful recovery 
without any complications. The growth, however, returned within 
a short time. 

Note .—This patient had perfect anesthesia by the method of 
infiltration block. The mandible was reached from the inferior 
aspect and the only reinforcement required was during the dis¬ 
articulation of the temporal mandibular joint. 


Report of Case No. 14106. 

W. S. W., aged forty-one years, entered the hospital January 
17, 1921. 

Diagnosis: Epithelioma of the lower lip. 

Operation: Block dissection of neck and excision of growth. 

Anesthesia: Local infiltration and cervical block. 

The growth appeared on the right lower labial border about 
five months before, and was cauterized one month before coming 
to the hospital. 

Operation: Bilateral block dissection of neck, excision of growth. 
A circumferential subdermal infiltration from the angles of the 
mouth downward and outward to the midpoint of the sternocleido¬ 
mastoid muscle and along the anterior border of this muscle to the 
clavicle was made on each side, as well as a bilateral infiltration 
block of the second, third and fourth cervical nerves. 120 cc of 
a 0.5 per cent novocain-adrenalin solution were used. Anesthesia 
was ideal. Transverse incision was made beneath the ramus of 
the jaw, with the flap dissected well below the cricoid cartilage, 
and block dissection upward with “V" shaped excision of the lip 
followed. This patient waited on himself throughout his con¬ 
valescence and developed no nausea, vomiting or thirst. 

The following cases show the possibilities of direct infiltration 
when for some reason the mandibular division cannot be blocked 
near its exit from the skull. 


Report of Case No. 14169. 

N. J., aged thirty-seven years, entered the hospital on March 
3, 1921. He had sustained a fracture of the base of the skull and 
a fracture of the left superior maxilla in addition to a fracture of 
the lower jaw. 

Diagnosis: Fracture of base of skull, left superior maxilla and 
left mandible. 

Operation: Wiring of the fragments of mandible. 


SURGERY OF THE FACE 


219 


Anesthesia: Local infiltration block with 2 per cent saligenin. 

On account of the injury to the upper jaw and base of the skull 
it was deemed unwise to attempt a mandibular block at the point 
of exit of the mandibular branch. Direct infiltration was there¬ 
fore depended upon and this was made, using a 2 per cent solution 
of saligenin, along the line of the proposed incision, with a trans¬ 
verse block 3 cm. proximal to the line of fracture, the needle being 
introduced from below upward along the ramus of the jaw on the 
inner side. The fragments were drilled and wired without pain 
to the patient. 


This case illustrates the possibility of using direct infiltration 
when for any reason the mandibular branch cannot be blocked 
at its point of exit from the skull or upon the inner surface of the 
ramus of the jaw. 


Report of Case No. 15752. 

R. S., aged eighty-two years, entered hospital June 1, 1922. 

Diagnosis: Carcinoma of the inferior maxilla. 

Operation: Excision. 

History: Growth appeared along left alveolar margin three to 
four months before entering hospital. 

Examination: Growth now extends from midline in front to 
the region of second molar. 

Operation: Excision of mandible June 4, 1922. 

Anesthesia Technic: Transoral mandibular block 10 cc of 1 
per cent novocain-adrenalin solution. 

A subdermal infiltration was made at right angles to the mouth 
beneath the chin, transversely backward to about the midline of 
the neck. The lower lip was divided in the midline, the right 
mental nerve was blocked at the mental foramen. The bone was 
divided on a line with the right lateral incisor and with the sub¬ 
lingual and submaxillarv glands and the gland-bearing tissues of 
the neck was turned outward and to the left. (See Fig. 59.) The 
mandible was then divided at the junction of the horizontal with 
the vertical ramus and removed. Before uniting the soft tissues 
the remaining ends of the lower jaw were drilled and a horseshoe¬ 
shaped brass wire was inserted in order to maintain the bones in 
proper position. The mucous membrane was sutured with chromic 
gut, the sublingual tissue being anchored to the temporary metal 
mandible. The skin incision was closed with silkworm gut with 
ample drainage through the floor of the mouth. Fig. 60 shows 
the patient at the completion of the operation. The patient was 
tired but the pulse remained about 80. There was no change in 
his general condition. The patient did well for six days and was 


220 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


sitting ii}) when his death occurred without warning. No autopsy 
was allowed but it was assumed that he died of pulmonary embolism. 
His lungs had shown no signs of pneumonia up to the time of his 
death. 

In the case of fractured mandible it is usually impossible to 
reach the third division by the transoral route. The same is 
true in malignant disease of the jaw extending well up along the 
ramus. In such cases it is desirable to block this branch near its 
origin. See mandibular block (Grant), Fig. 55, page 215. 



Fig. 59. Case No. 15752.—Carci¬ 
noma of the lower maxilla during oper¬ 
ation. 


Fig. 60. Case No. 15752. —Carci¬ 
noma of the lower maxilla at the com¬ 
pletion of operation. 


SKIN PLASTICS. 

Plasties upon the face are usually done in the same manner, 
the infiltration being but the work of a moment. As a rule it is 
made at some distance from the lines of incision, although this is 
not important. The thickening of the tissues caused by the infil¬ 
tration we find is rather an advantage than otherwise in the final 
coaptation of the wound by the suture, as it enlarges the structures 
with which one has to deal. The action is very transient. 

All the external soft tissues of the face may be blocked by injecting 
the corresponding nerves at their point of exit, but here a direct 
infiltration is exceedingly simple and satisfactory. 

Hare-lip. —Of late, operation upon hare-lips in infants under 
local anesthesia has been found satisfactory. A slight infiltration 
is made along the lines indicated in Fig. 01; a submucous injection 
is made along the alveolar border in the region of the root of the 
nose and the operation then proceeds without delay. One might 










SKIN PLASTICS 


221 


assume that the edematization of the tissues would interfere with 
the apposition of the parts, but such is not the case. Quite obviously 
if the tissues on either side of the cleft are increased equally in 
thickness as a result of the infiltration, the ultimate coaptation 
of the denuded edges meets with no interference. Indeed, it has 
been found that the increased thickness of the tissues, resulting 
from the infiltration, offers a better opportunity to obtain neat 
coaptation, as the increased thickness of the lips makes them 
more easy to handle. These babies frequently show a normal 
temperature during the day following operation, whereas those 
who have taken ether usually show a marked elevation of temper¬ 
ature and a tendency to bronchial irritation. 



Fig. 61.—Showing lines for infiltration block in hare-lip operations. 


Report of Case No. 14300. 

B. D., aged twelve weeks, entered the hospital, March 3, 1921. 

Diagnosis: Hare-lip and cleft palate. 

Operation: Plastic repair of lip. (Second step—Brophy pro¬ 
cedure.) 

Anesthesia: Local infiltration. 

History: Reposition of alveolar processes with Brophy wiring, 
eight weeks previously. Two weeks previously, removal of wires. 

Anesthesia Technic: An infiltration block was carried out along 
the lines indicated in Fig. 61, the child being forcefully restrained 
while the injection was being made. The restraint for the initial 
wheal about equals that of ether induction. As anesthesia of the 
lips became established they were elevated by means of towel 
pins and a submucous infiltration along the alveolar processes was 



222 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


carried out. The classical operation was then completed with¬ 
out difficulty. 

Note .—This patient did not vomit after the operation. He 
took food almost immediately and his temperature was 98 degrees 
on the following day. His maximum temperature remained under 
100 degrees. 

In the author’s experience children show much less tendency to 
bronchial irritation and postoperative elevation of temperature 
when local, rather than general anesthesia, is employed. 



Fig. 62.—Nerve supply of the tonsil. A, Nn. palatini; B, N. glossopharyngeus; 
O, rami tonsillares. 1, ganglion semilunare (Gasseri); 2, ganglion sphenopalatinum 
(Meckel); 3, Nn. palatini (anterior, middle and posterior); 4, N. glossopharyngeus; 
5, tonsil; 6, rami tonsillares. 


SURGERY OF THE MOUTH AND THROAT. 

The Tonsils.—The sensory nerve supply of the tonsil region is as 
follows: 

1. Rami tonsillares, branches of n. glossopharyngeus (IX) supply 
the palatine tonsil, forming a network. 

2. Sensory branches from the sphenopalatine ganglion of n. 
trigeminus. 

3. N. palatinus medius, n. palatinus posterior, of n. maxillaris, 
second division of n. trigeminus. (Fig. 62.) 

Tonsillectomy— Infiltration .—It is desirable to avoid infiltration 
of the pillars when doing tonsillectomy under local anesthesia. 


























































SURGERY OF THE MOUTH AND THROAT 


223 


It is much better to reach the nerve supply at a distance. (Figs. 
62 and 63.) 

When blocking is done in this manner the position of the tonsil 
is not obscured by the edema. The nerve supply is blocked as 
illustrated in Fig. 62 and 63, A, B and C. An infiltration block is used 
and the needle-point is kept moving while the injection is being 
made. In this manner one avoids the possibility of introducing 
any considerable amount of solution into a vessel. 



Fig. 63.—Anesthesia for tonsillectomy. (See Fig. 62.) 


An injection at (A) anesthetizes the posterior palatine branch 
of the maxillary division of the trigeminus and with the needle at 
( B ) the plexus of nerves from the glossopharyngeus and the spheno¬ 
palatine ganglion are reached, and at (C) (which point is dis¬ 
tinguished by putting the palatoglossal muscle on the stretch) 
the anesthesia of the arborizations of some nerves of the inferior 
pole of the tonsil completes the injection. 

A very satisfactory method is the subcapsular injection of the 
solution,' but this method demands more finesse and skill of the 
surgeon than when the infiltration block, described above, is carried 

out. 




























































224 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


The tissues in which these nerves lie are best visualized by 
depressing the tongue. Finally, a small amount of* the solution 
is deposited external to the tonsillar capsule. Approximately 
8 cc of 0.7 of 1 per cent solution are required, and anesthesia is 
complete almost immediately. In these cases a careful blocking 
with quinin and urea hydrochloride 1 to 600 in all raw surfaces 
will have a marked effect in preventing the distress which follows 
operation, especially in adults, and will aid in reducing the liability 



Fig. 64. —Blocking the lingual nerve. Sublingual method 


to postoperative hemorrhage. The practice of making local appli¬ 
cations of strong solutions of cocain to the mucous surface of the 
throat is extremely dangerous and entirely unnecessary. 

Surgery of the Tongue.—The nerve supply of the tongue is as 
follows: Anterior two-thirds; n. lingualis, a branch of the third 
division of the n. mandibularis. 

Base and posterior one-third: Rami lingualis, branches of n. 
glossopharyngeus and ramus interims of the superior laryngeal 
branch of n. vagus. (Plate II.) 












































































SURGERY OF THE MOUTII AND THROAT 


225 


Operations upon the tongue may be accomplished after a bilateral 
injection of the lingual nerve (Figs. 64 and 65) or a mandibular 
block (Fig. 56, page 215, and page 205). It is advisable to make 
the injection bilateral, provided work of an extensive nature 
is to be done. I he author has excised half the tongue for malig¬ 
nant disease a number of times under this method of anesthesia. 
He has not attempted the complete removal of the tongue 
under local anesthesia, although the removal of portions of the 



Fig. G5.—Sectional view of Fig. 64.—1, A. maxillaris interna; 2, N. ophthalmicus; 
3, N. buccinatorius; 4, ganglion semilunare (Gasseri); 5, N. mandibularis; 6, N. 
lingualis. 


tongue under this method is a comparatively simple matter. Com¬ 
plete excision of the tongue, if ever indicated, should not be 
attempted without an excellent exposure, and with perfect exposure 
it should be possible, and it would seem to be feasible, to infiltrate 
the base of the tongue below the point of excision. Allen states 
that general anesthesia is indicated in complete excision of the 
tongue, but, in view of the fact that most of these patients succumb 
to pulmonary infection, local anesthesia would seem to be indicated, 
15 
















226 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


The operation should be possible under a nerve block of the inferior 
dental and lingual on both sides and a transverse block below. 
If the growth is so extensive that this block would be inadequate 
it is doubtful if an operation of any kind would be indicated. The 
preliminary division of the lower jaw at the symphysis menti 
(after Kocher) would be of advantage. The author has not had 
the opportunity of performing this operation. 



Fig. 66.—Anesthesia for operations upon the soft palate. A, B, C, points for 
blocking nerves of palate. (See page 168 and Fig. 62.) 

The Palate.— After early adolescence the palate may be anes¬ 
thetized by blocking the n. palatinus posterior, n. palatinus medius, 
and n. palatinus anterior of n. maxillaris, second division of n. 
trigeminus and n. nasopalatinus (Fig. 62, page 222). Cleft palate 
plastics have been performed by the local method upon a patient 
as young as fifteen years. (Case No. 11400.) The absence of 
hemorrhage, the cooperation of the patient and the almost entire 
elimination of disagreeable sequelie would seem to indicate that 
local anesthesia should be used more frequently in cleft palate 
work in the adult, and also in the removal of tumors of the palate. 
The line of cleavage between the bone and the mucoperiosteum 
of the palate may be infiltrated with a solution, under pressure, 



































SURGERY OF THE MOUTH AND THROAT 


227 


thus greatly facilitating the elevation of the latter. The adrenalin 
greatly reduces the amount of hemorrhage and in the few eases 
in which the author has used it healing was excellent. The points 
of injection are illustrated in Fig. 66 , A, B and C, using about 
50 cc of 2 per cent novocain-adrenalin solution. Cases Nos. 14115, 
14281 and 11400 show the application of the above method in 
surgery of cleft palate. 


Report of Case No. 14115. 

E. M., aged twenty-five years, entered the hospital on January 
21, 1921. 

Diagnosis: Cleft palate. 

Operation: Plastic repair. 

Anesthesia: Novocain-adrenalin solution. 

The nerves illustrated in Fig. 62, page 222, were blocked at 
points A, B and C, Fig. 66, with a 2 per cent novocain-adrenalin 
solution, 30 cc in all being used. In addition to the nerve block 
an effort was made to separate the soft tissues from the bone by 
the “ blowing-off” process. This was signally successful, the 
subsequent raising of the mucoperiosteum being greatly facilitated 
by this preliminary maneuver. The palate united completely 
with the exception of an opening the size of a lead-pencil at the 
midpoint. This opening was later closed after making a local 
infiltration with novocain-adrenalin solution. 


Report of Case No. 14281. 

K. E., aged twenty-six years, entered the hospital on May 27, 

1921. 

Diagnosis: Cleft palate and hare-lip. 

Operation: Plastic repair. 

Anesthesia: 60 cc of a 2 per cent novocain-adrenalin solution 
were used. 

The blocking in this case was similar to that referred to in the 
case of E. M., above, and the anesthesia was ideal. Healing was 
perfect throughout the line of suture. 

Report of Case No. 11400. 

The youngest patient upon whom the author has operated for 
cleft palate under local anesthesia was A. M., aged fifteen years, 
who entered the hospital on March 8, 1918, 

Diagnosis: Cleft palate. 

Operation: Plastic repair. 



228 LOCAL ANESTHESIA IN SURGERY OF HEAD AND FACE 


Anesthesia: Local infiltration, novocain-adrenalin 2 per cent. 

Linder ideal anesthesia this complete cleft was repaired and the 
repair was followed by primary healing. This boy had been 
operated upon twelve years previously, and notwithstanding the 
presence of scar tissue perfect anesthesia was obtained. 

Note .—This was the first case of cleft palate the author operated 
upon under local anesthesia, and it was done on March 8, 1918. 
At the beginning of the operation a 0.7 of 1 per cent novocain- 
adrenalin solution was employed, but it was found unsatisfactory 
on account of the presence of scar tissue and 2 per cent was sub¬ 
stituted. Since that time about 50 cc of a 2 per cent solution has 
been employed for each operation. 




CHAPTER VIII. 


LOCAL ANESTHESIA IN SURGERY OF THE NECK. 

GENERAL CONSIDERATIONS. 

Advantages. —In this region local anesthesia presents many 
special advantages over general. By its use hemorrhage is greatly 
reduced; (1) through the action of the adrenalin solution; (2) 
through the reduction in local engorgement of the bloodvessels, 
especially the veins. Under local anesthesia we have frequently 
demonstrated the fact that a patient may control at will his own 
bleeding from the internal jugular vein, an expulsive effort causing 
the blood to spurt from the wounded vessel, perfect repose causing 
the vessel to cease bleeding and deep inspiration causing a negative 
pressure in the vein. 

Cooperation of the Patient. —Under local anesthesia the co¬ 
operation of the patient is obtained, as his head may be turned from 
side to side at will, respirations may be controlled, ability to use the 
voice may be ascertained, the patient may go through the process 
of swallowing if directed to do so and the interference caused by the 
presence of an anesthetist is not encountered. Following the 
operation the respiratory function is not impaired and the chance 
of soiling wounds by vomitus is reduced to a minimum. 

The work upon the neck, aside from that in which the trachea 
is manipulated, may be carried out with the same dispatch, and if 
desired, practically the same technic as when general anesthesia is 
used. Operations upon the thyroid, larynx and trachea require a 
more refined technic than is usually seen when general anesthesia 
is employed. 

NERVE SUPPLY OF THE NECK. 

The sensory nerve supply of the neck is as follows: 

The skin of the neck is supplied by (1) n. cutaneus colli (II, 
III C) to the antero-lateral regions, by way of the ascending 
branches which supply the upper front part, and the descending 
branches to the side and front as low as the sternum; (2) a cervical 
communicating branch of the facial; (3) nn. supraclaviculares 
anteriores (III, IV C) also to the lower and front part of the neck 
and (4) medial branches of the posterior divisions of the third, 
fourth and fifth cervicals which supply the posterior or dorsal 
region. 


230 LOCAL ANESTHESIA IN SURGERY OF THE NECK 


The muscles and fascia of the neck are supplied by branches of 
practically the same cervical nerves mentioned above and the over¬ 
lapping of the trigeminal with the cervical cutaneous nerves does 
not always take place at the mandibulo-cervical line, which requires 
that the terminal branches of the mandibular division of n. tri¬ 
geminus be also included in the sensory nerve supply of the neck. 
(Plate IV.) 

METHOD OF INDUCING ANESTHESIA. 

The skin and the cervical fascia are the most sensitive structures. 
While blocking of the cutaneous colli will give anesthesia of the 
superficial structures of the neck, the deep structures cannot be 
manipulated under this anesthesia alone and more extensive anes¬ 
thesia is necessary for work that is at all extensive. The second, 
third and fourth cervicals should be blocked at or near their point 
of exit from the cervical vertebrae. This blocking should be bilateral 
for work that traverses the midline in front. 

As the terminal branches of the nerves cross the midline and over¬ 
lap the trigeminus branches, it is advisable to block the skin around 
the field of operation by a subdermal infiltration. It has been the 
custom of the author also to make a subdermal infiltration along the 
proposed line of incision. This procedure allows one to make the 
incision as soon as the injection is finished. Otherwise some delay 
is necessary while the solution disseminates into the nerve structures. 
The subdermal infiltration, which is but the work of a moment, is 
made directly under the eye and all large vessels can be seen and 
avoided. A subdermal infiltration will render incisions almost 
bloodless and give good anesthesia during the early stages of the 
operation, at which time the patient is liable to be most appre¬ 
hensive. 


DEEP CERVICAL INFILTRATION. 

In making the deep cervical infiltration block the suggestions 
of Braun have been followed with some modifications. His instruc¬ 
tions are to drop a vertical line from the tip of the mastoid process 
downward 7 cm. and slightly backward, forming an acute angle with 
the sternocleidomastoid. This line marks the point of emergence 
of the second, third and fourth cervical nerves, and according to 
Braun’s technic the needle is introduced transversely through a 
series of punctures made along this line. The author has modified 
this technic to some extent. An intradermal wheal is made at 
about the midpoint of this line by introducing a needle through a 
previously anesthetized area anteriorly and carrying it back through 
the subdermal fat, making this wheal from beneath. All of the 
deep blocking is then made through this wheal (Figs. G7 and 68). 


DEEP CERVICAL INFILTRATION 


231 



Fig. 67.—Anesthesia for block dissection of the neck, showing lines of subdermal 

infiltration, and A, block of cervical plexus. 



Fig. 68.—Sectional view of Fig. 67. 1, N. cervicalis I; 2, N. cervicalis II; 3, N. 

cervicalis III; 4, N. cervicalis IV. A, cervical block showing position of needles. 

































232 LOCAL ANESTHESIA IN SURGERY OF THE NECK 


The needle is introduced first in a slightly upward direction, then 
introduced transversely and again introduced in a slightly down¬ 
ward direction. In reintroducing the needle it need not he withdrawn 
from the shin hut must he withdrawn from the cervical fascia each 
time that its direction is changed. 

The injection is made as follows: Before injecting, the needle 
is advanced until it touches the transverse process of one of the 
cervical vertebrae or until it impinges upon a nerve. It is then 
slowly withdrawn, the injection being made while it is receding 
and while it travels a distance of 1 or 2 cm. Should the needle 
impinge upon a nerve, a circumstance which is manifested by a slight 
shock to the patient (a circumstance which is desirable rather than 
otherwise), the injection should be made without withdrawing the 
needle. But a small amount of the solution is necessary under 
these conditions. It is the practice of the author to introduce the 
needle four or five times into the deeper tissues in making a single 
infiltration block of one side. The margin of error is slight and the 
discomfort to the patient is negligible. 

The only structures of note which are to be avoided are the deep 
jugular vein and the carotid artery, and these lie well in front of the 
path of the needle and the vertebral artery, which will not interfere, 
provided the needle point is kept moving. A possible source of 
error comes from making the injection on a line too far posterior, 
and in this case the nerve trunks might not be reached by the solu¬ 
tion. Should malignant or tuberculous tissue present along the 
line through which the needle is to be passed, the injection may be 
almost as easily made from behind. One has only to keep in mind 
the “geography” of the parts and bring the needle point into the 
proper area before the injection is made. Careful adherence to this 
technic should give complete anesthesia to the lateral half of the neck. 
Twenty to 30 cc of a 0.5 to 1 per cent solution is ample for each side. 

A subdermal infiltration along the ramus of the jaw interrupts 
the branches of the trigeminus, some branches of which supply the 
upper portion of the neck (Fig. 67). Provided the sublingual and 
parotid regions are to be attacked it may be desirable to block the 
mandibular branch, as described on page 215. However, good 
anesthesia has usually been obtained by the use of a subdermal 
infiltration, combined with an infiltration internal to the ramus 
of the jaw, made from below and after the ramus had been exposed 
in the dissection. 

TUBERCULOUS GLANDS AND MALIGNANT DISEASE. 

As the surgical removal of tuberculous glands of the neck and 
malignant tissue comprehends a complete excision of all gland- 



TUBERCULOUS GLANDS AND MALIGNANT DISEASE 233 


bearing tissue this operation should not be attempted under local 
anesthesia without the establishment of a complete interruption of 
the cervical nerves as described on page 230. The greatest dissatis¬ 
faction results from an attempt at removal of apparently isolated 
groups of tuberculous glands which are firmly attached to or are 
beneath the cervical fascia when complete anesthesia has not been 
established. In malignant disease also one should prepare before 
the operation is begun to carry out a complete dissection and thus 
avoid the embarrassment of finding that the anesthesia is incomplete 
at some stage of the operation. Removal of branchial cysts and all 
tumors demanding an extensive dissection should be preceded by a 
complete blocking of the cervical nerves. Small tumors which are 
adherent to the skin may be excised under circumferential infiltra¬ 
tion. Abscesses may be drained under direct infiltration. 

Cases No. 14205, 9751, 12271, 12498, 11694 and 13911 are 
respectively examples of suppurative and tuberculous cervical 
adenitis in children and in the aged, as well as carcinoma of the 
lower lip and carbuncle of the neck, all of which were treated 
surgically with local anesthesia. 

Report of Case No. 14205. 

The following case, one complicated by malnutrition, will illustrate 
the application of local anesthesia in children in whom the establish¬ 
ment of general anesthesia would seem especially hazardous: 

B. I)., aged nine months, the child of a physician, entered the 
hospital on February 27, 1921. This child had suffered from 
malnutrition since birth, and at the time he entered the hospital 
presented a fluctuating mass in the left side of the neck, with which 
he had been ill for three weeks. 

Diagnosis: Suppurative cervical adenitis. 

Operation: Incision and drainage. 

Anesthesia: Local infiltration, 20 cc of a 0.5 per cent novocain- 
adrenalin solution. 

The child was forcibly restrained and a direct infiltration was 
made over the swelling, using 20 cc of a 0.5 of 1 per cent novocain- 
adrenalin solution. The skin was picked up with towel pins to 
avoid pressure and a transverse incision was made down to the 
cervical fascia. At this point the operation was delayed while the 
cervical fascia was infiltrated. This layer was then picked up with 
towel pins and a sharp-pointed hemostat was forced through and 
spread widely, opening the abscess. 

Report of Case No. 9751. 

W. A., aged five years, entered hospital January 3, 1916. 

Diagnosis: Tuberculous cervical adenitis. 


234 LOCAL ANESTHESIA IN SURGERY OF THE NECK 


Operation: Complete dissection of the neck. (Oassical subdermal 
infiltration and block of the cervical nerves. 1 ransverse incision 
12 cm. in length. 

Anesthesia: 90 cc of 0.7 of 1 per cent novocain-adrenalin solution. 

A mass of glands the size of an adult fist was excised, and although 
anesthesia was not complete, and the child complained during the 
deeper part of the dissection, and anesthesia had to be reinforced, 
the operation was completed without the child crying (Fig. (59). 



Report of Case No. 12271. 

R. H., aged nineteen years, entered the hospital on September 9, 
1919; referred by Dr. Id. W. Wittich. 

Diagnosis: Bilateral cervical adenitis (tuberculous). 

Operation: Block dissection of the neck (right side). 

Anesthesia: Local infiltration, cervical nerve block. 

160 cc of a 0.7 of 1 per cent novocain-adrenalin solution were used, 
and a rhomboid subdermal infiltration was made, combined with 
an infiltration block of the second to the fifth cervical nerves at 
their points of exit (see Fig. 68, page 23). The patient had 
received very extensive treatments with the roentgen ray and her 
neck presented a mass of scar tissue. A complete block dissection 
was made under perfect anesthesia (Fig. 67, pages 231-235, and 
Fig. 70). 

On October 3, 1919, the patient reentered the hospital for a dis¬ 
section of the opposite side and the same procedure was carried out. 

Note .—This case illustrates the excellence with which local 
anesthesia of the neck may be used even in the presence of scar 
tissue, which makes these dissections difficult. 







TUBERCULOUS GLANDS AND MALIGNANT DISEASE 235 

The following case illustrates the application of local anesthesia 
in the removal of multiple tuberculous foci in old and otherwise 
handicapped individuals. 



Fig. 70.—Tuberculous cervical adenitis block dissection of neck, photograph taken 

during operation. (Case No. 12271.) 


Report of Case No. 12498. 

S. J., male, aged seventy-two years, entered the hospital on 
December 26, 1919. 

Diagnosis: (1) Tuberculous cervical adenitis. 

(2) Tuberculous epididymitis and orchitis (right side). 

Operation: (1) Block dissection of neck. 

(2) Right orchidectomy. 

History: This patient had had enlarged glands of the neck, 
right side, for three years. These had begun to break down during 
the past three weeks. One month ago noted swelling and soreness 
of the right epididymis. Seminal vesicles not tender. Prostate 
enlarged somewhat. 

Anesthesia Technic: December 29, 1919, the tuberculous testicle 
and epididymis were removed under local anesthesia, 75 cc of 0.5 
per cent novocain-adrenalin solution were used, making an infiltra¬ 
tion block of nn. ilioinguinal and iliohypogastric, and as the cord 
was exposed it was thoroughly infiltrated. The pudic nerves were 
blocked as shown under hydrocele (Fig. 139, page 344). 

The patient was allowed to leave the hospital in a few days and 
he returned March 3, 1920, at which time he had a complete dissec¬ 
tion of the right side of his neck, using the anesthesia technic 
described on page 231, Figs. 67 and 68, 120 cc 0.5 per cent novocain- 
adrenalin solution being employed. 

The following case will illustrate the technic of classical dissection 
of the neck followed by excision of epithelioma of the lower lip. 





236 LOCAL ANESTHESIA IN SURGERY OF THE NECK 


Report of Case No. 11694. 

C. M., male, aged fifty-two years, entered hospital September 7, 
1918. 

Diagnosis: Epithelioma of lower lip. 

Operation: Block dissection of neck; excision of growth. 

Anesthesia: Local infiltration; bilateral cervical block. 

History: Patient has not smoked for three years. During the 
last three weeks he has presented a growth on the lower lip, right 
side. 

Anesthesia Technic: The classical infiltration, block, similar to 
that described in Figs. 67 and 68, except that it was bilateral. 
Both sides of the neck were carefully dissected, although no enlarged 
nodes could be palpated. 



Fig. 71. —Carcinoma of the lip. Photo of Case No. 11694 undergoing block dissec¬ 
tion of neck. 


A transverse excision of the lower lip was then made. 

Photo Fig. 71 shows the patient undergoing the operation. 

The following case illustrates the application of infiltration block 
in cases of carbuncles, of which we have removed many by this 
method. 

Report of Case No. 13911. 

P. C., aged forty-five years, physician, entered the hospital on July 
16, 1920, presenting a large carbuncle on the back of his neck. He 
objected strenuously to taking general anesthesia. 

Diagnosis: Carbuncle of neck. 

Operation: Excision. 





THE THYROID 


Anesthesia: Infiltration block, using GO cc of 0.5 of 1 per cent 
novocain-adrenalin solution. 

Operation: The infiltrating needle was carried 5 cm. beyond the 
outer edge of the carbuncle until the latter had been completely 
isolated from its nerve supply, when it was removed, absolutely 
without pain to the patient. The base was then cauterized and 
packed. The wound healed kindly. 


THE THYROID. 


The nerve supply to the thyroid is as follows: The thyroid nerve 
supply consists of sympathetic nerves derived from the middle and 
inferior cervical ganglia, but in the surgery of this gland the sensory 
nerves of the neck (Plate IV) are involved. To review, they are 
(1) n. cutaneus colli (II, III C), (2) nn. supraclaviculares anteriores 
(III, IV C), (3) a communicating cervical branch of n. facialis and 
(4) terminal overlapping branches of the mandibular division of 
n. trigeminus, thus showing that in the surgery of the thyroid the 
second to fourth cervical and the fifth and seventh cranial nerves 
are involved as well as the very important closely lying n. recurrens 
of the vagus as it passes through this region to the larynx. 

Thyroidectomy in Non-toxic Cases. — Anesthetic and Surgical 
Technic.—Thyroidectomy demands bilateral blocking of the second, 
third and fourth cervical nerves, as described on page 230. The 
operation is facilitated by the making of a subdermal infiltration 
over the surface of the gland. The technic employed by the author 
is as follows: 

Superficial and Deep Infiltration.—A wheal is made at any 
convenient point over the surface of the gland and from here the 


whole area is raised by a subdermal infiltration, Fig. 


The 


veins can be seen and easily avoided. The solution may be used 
in generous amounts. From the posterior border of this field 
the needle point is carried beneath the shin on each side to a position 
about 3 cm. below the mastoid process and a wheal is painlessly 
produced from beneath. From this wheal the second, third and 
fourth cervical nerves are blocked at their point of emergence from 
the spine (Fig. 72, A, A', Fig. 68, page 231). Approximately 30 cc 
of solution is used subdermally and 15 cc of solution used in the 
blocking of the cervical nerves on each side. The incision may then 
be made without delay and the flaps dissected upward and down¬ 
ward. 

The use of the Automatic Retractors, Figs. 73 and 74, facilitates 
this procedure by carrying the divided skin edges apart and by 
eliminating rough or asymmetrical traction and pressure, which 
are a common cause of complaint when carelessly performed. 


238 LOCAL ANESTHESIA IN SURGERY OF THE NECK 


The gland should be approached by means of sharp dissection, 
using forceps to elevate the structures as they are being cut (Fig. 
74). Good exposure by clamping and cutting the muscle layer, 
as shown in Figs. 75 and 76, will facilitate dissection. The most 



Fig. 72.—Anesthesia for thyroidectomy. Subdermal infiltration, and A, A', block 

of cervical plexus. 



Fig. /3. Thyroidectomy. Skin incision showing action of wire spring retractors. 















THE THYROID 


239 


sensitive region encountered will be the area through which the 
superior thyroid vessels and sympathetic nerves enter the gland. 
Y\ hile formerly it was our practice to forcibly separate the gland 
laterally from the surrounding structures, we have found that 



v. 


Fig. 74.—Thyroidectomy. Muscles exposed. 



Fig. 75.—Thyroidectomy. Preparation for division of muscles. Bainbridge 

forceps (Fig. 17) applied. 



















240 LOCAL ANESTHESIA IN SURGERY OF THE NECK 


excision is much simplified by beginning at the medial side above. 
As the gland is separated from the trachea slight traction may be 
made upon the superior thyroid vessels. The slightest discomfort 



Fig. 76. Thyroidectomy. Muscle divided. Automatic spring retractor in place. 



Tig. it. Thyroidectomy. Cdand mobilized. Goiter holding forceps in use. 

to the patient demands an immediate infiltration of the upper pole, 
which now comes plainly into view. In the case of large tumors, 
as soon as a sufficient amount presents it is grasped by the goiter 










THE THYROID 


241 


clamp (Fig. 10, page 104, and Figs. 77 and 78). By means of this 
instrument the gland may be perfectly controlled, pressure upon the 
trachea may be avoided and, provided a large amount of the gland 
is grasped by the clamp, bleeding from the gland and the forcing 
of “ goiter juice” into the patient’s body are prevented. Incidentally 
the number of hemostats required is greatly reduced, it being 
necessary to place forceps only upon the proximal side of the pedicle. 
When severing the gland from its mesial attachment to the trachea 
it is desirable to require the patient to speak after the placing of 
each pair of artery forceps and before the tissues are severed. 
The patient may be asked to say “Good-morning.” Should the 



Fig. 78 .—Photograph of patient undergoing thyroidectomy. Goiter holding forceps 

in use. 

voice show hoarseness, the artery forceps must immediately be 
removed and replaced at a greater distance from the trachea. In 
this manner one may avoid the possibility of severing the recurrent 
laryngeal nerve. 

The routine use of the above method of obtaining anesthesia, 
regardless of the size of the gland, will be found advisable. . The 
nerve supply of the thyroid does not vary, regardless of the size of 
the gland. ' Therefore, the large intrathoracic goiters may be as 
easily removed from the standpoint of the anesthesia as may the 
smaller ones. Under local anesthesia, by observing the above- 
mentioned rules of procedure the patient may, with but slight 
16 








242 LOCAL ANESTHESIA IN SURGERY OF THE NECK 


assistance on the part of the operator, expel his tumor from the 
chest cavity after the superior restraining bands are severed and 
entirely without discomfort. 

Cases No. 14588 and 13951, which follow, are included as examples 
of mildly toxic colloid goiters treated surgically under local anes¬ 
thesia. Saligenin was used in the latter. 

Report of Case No. 14588. 

C. C. H., male, aged forty-six years, entered the hospital on 
December 5, 1921. 

Diagnosis: Toxic colloid goiter. 

Operation: Partial lobectomy. 

Anesthesia: Local infiltration and cervical block. 



Fig. 79.—Photograph of_Case No. 14588 undergoing thyroidectomy. 

120 cc of a 0.5 per cent novocain-adrenalin solution were used and 
a classical subdermal infiltration and cervical block was made. 
60 cc of 0.5 per cent novocain-adrenalin solution were introduced 
subdermallv and 30 cc were used on each side for blocking the 
cervical nerves. A large intrathoracic colloid goiter was removed 
from the left and a small adenoma from the right. Fig. 79 shows a 
photograph of the patient during the operation. 

Report of Case No. 13951. 

Saligenin 2 per cent has been employed a number of times, using 
a similar technic with equally good results. The low toxicity of 
this drug makes its employment seem desirable. 

G. E., aged fifty-five years, entered the hospital on August 16, 
1920. 







THE THYROID 


243 


Diagnosis: Intrathoracic toxic thyroid adenoma. 

Operation: Partial lobectomy. 

Anesthesia: Local infiltration and cervical block. 120 cc of a 
2 per cent solution of saligenin were used. 

A classical infiltration and infiltration block was made, and an 
ideal anesthesia obtained. 

Toxic Thyroids.—Ligation of the Thyroid Arteries.—A preliminary 
ligation of the thyroid vessels, only one of which should be ligated 
at a single sitting, becomes one of the most excellent means of 
preparing the toxic case for the radical operation. Necessary as is 
the obtaining of perfect anesthesia for the performance of the major 
operation, this to my mind is of secondary importance as compared 
with the avoidance of any pain whatever during any of the ligations. 
None of these ligations are called operations in the patient’s presence 
and each, like the preliminary trips to the operating room is 
referred to as a “treatment.” While surgical judgment, founded 
upon experience and careful observation, combined with the various 
laboratory aids, is extremely helpful in arriving at an opinion as to 
when to perform the various ligations and when to perform the 
major operation, nothing has given more satisfaction in indicating 
the time to ligate or to operate than the reaction of the patient to 
the various trips to the operating room for the purpose of administer¬ 
ing “treatment.” 

"Technic.—Ligation of the Thyroid Arteries.— The ligation of the 
superior or inferior thyroids may be made under direct infiltration. 
It is well to outline carefully the exact location at which one desires 
to make the incision, otherwise too profuse edematization of the 
tissues may result in the loss of one’s landmarks. The skin is 
anesthetized and a fine needle introduced vertically until the 
fascia is reached. One need not hesitate to use a considerable 
amount of the fluid, keeping the needle moving while the fluid is 
being introduced. Provided one wishes to obtain a good exposure 
of the vessels a fairly extensive infiltration is necessary. Tinker 
has called attention to the fact that there may be several superior 
thyroid branches and complete anesthesia of the whole area involved 
is desirable so that an excellent exposure may be obtained. 

Thyroidectomy in Toxic Cases.— The surgical removal of the toxic 
thyroid demands a slight departure from that used in the simple case. 
The amount of adrenalin should be reduced to the minimum. During 
recent years the author has employed only 1 minim of 1 to 
1000 adrenalin to 30 cc of solution. An effort should be made 
to establish the most perfect anesthesia possible. The psychic 
element becomes a very important factor in the surgical treat¬ 
ment of this disease and the reader is referred to the chapter on 
the preparation of the patient (page 135) for details. Experience 


244 LOCAL ANESTHESIA IN SURGERY OF THE NECK 


lias shown that many of these individuals present a high degree of 
intelligence and a desirable cooperative spirit. True, they may 
present marked evidences of apprehension. Much depends on the 
successful carrying out of the preoperative schedule, but the out¬ 
standing cause of increased excitability, rapid pulse, restlessness, 
complaint of extreme heat, thirst, etc., almost always follows 
failure to obtain complete and thorough anesthesia. 

Crile perhaps deserves the credit for the so-called “stealing” 
of the operation in the toxic thyroic case; there are a number of 
methods of carrying out this procedure. One must obtain the 
consent of someone who is responsible for the patient and make 
full arrangements concerning the treatment. The patient is to be 
kept in ignorance regarding the operation and yet authority must 
be given the surgeon so that he may perform an operation at any 
time he deems it advisable; even though the patient gains an 
indistinct impression that an operation is to be performed, it is 
desirable to allow him to think that the date set is more or less 
distant so that he will not be particularly apprehensive, as these 
patients are apt to be, provided they are allowed to plan on a 
definite day, as is the rule, in the case of other types of operations. 

The plan that the author has followed has been to obtain permis¬ 
sion to carry out the surgical treatment in the manner in which his 
judgment dictates. The patient is then offered every aid in a 
medical way (rest, fluids, quiet, digitalis, sedatives, etc.) that one 
can furnish. In addition the course of preliminary treatment is 
begun; this consists (1) in giving the patient a sterile hypodermic 
early each morning. Stock solution of novocain is usually employed 
for this hypodermic on account of the fact that it may be given 
without distress to the patient. (2) The leather stretcher pads 
(page 102 Fig. 15, A, B, C ) are placed beneath the patient with as 
little disturbance as possible. (3) The patient is given no food but 
allowed to drink freely of liquids until the third step of the treat¬ 
ment has been completed. (4) The patient is carefully transported 
to the operating room by means of the automatic lifter (Fig. 15, 
page 102) and carefully placed upon the operating table. (5) The 
neck is bathed with alcohol or some other substance which has a 
distinct odor capable of perception by the patient. (0) A hypo¬ 
dermic needle is introduced beneath the skin and allowed to remain 
for a few minutes while the neck is pressed upon and certain maneu¬ 
vers carried out which simulate as nearly as possible the preliminary 
steps of the average thyroidectomy or ligation. (7) The patient 
is given to understand that this camouflage trip to the operating 
room constitutes a “ treatment.” (8) The patient is now returned to 
bed after a bandage has been applied to the neck and encouraged in 
every manner possible to think that his trip to the operating room 


THE THYROID 


245 


has been a success and that he has withstood the ordeal well. (9) 
A careful chart of the pulse-rate and general condition of the patient 
is kept and the frequency of the “treatments” is regulated by the 
patient’s reaction. The record of the patient’s reactions furnishes 
one with a new basis upon which to estimate the relative safety of 
surgical attack. Case No. 8691 is an example of an extremely toxic 
goiter which was successfully treated surgically by the use of local 
and narco-local anesthesia. 


Report of Case No. 8691. 

C. I)., female, aged twenty-one years, student at University. 

Diagnosis: Exophthalmic goiter. 

Operation: Multiple ligations. Injection of quinin-urea hydro¬ 
chloride. Lobectomy. 

Anesthesia: Narco-local and local infiltration. 

History: The patient’s symptoms date back only two months. 
She entered the hospital December 13, 1915, and was discharged 
May 3, 1916. The pulse ranged from 120 to 160. Her eyes were 
extremely prominent and she was in a very toxic condition. She 
was unable to retain food, had marked diarrhea and tremor and had 
lost fifty pounds in weight. 

Treatment: Rest, sedatives and radio-therapy were employed for 
twenty-two days when the right superior pole was ligated and 
divided under local anesthesia. During the operation the patient’s 
pulse became so rapid that it could not be counted. At the end 
of twenty-four hours it was 170 and of extremely poor quality. 
This ligation was thought advisable as the patient’s condition had 
been growing steadily worse. Digitalis was employed with good 
effect, the pulse dropping to 150 on the third day, and one month 
later the pulse averaged 125 to 135. Five weeks after the ligation 
of the right superior thyroid the left lobe of the gland was injected 
with 4 cc of quinin-urea hydrochloride, 30 per cent. 

Injection of Quinin and Urea Hydrochloride. — The skin was 
anesthetized with novocain solution and the needle was inserted 
into the gland, the quinine solution being injected into various 
portions of the gland, with only slight pain to the patient. Nine 
days later a second injection of 40 per cent quinine was made into 
the same lobe. The patient gradually improved. On April 30, 
four and a half months after admission, an attempt was made to 
get the patient into a sitting posture, but the pulse reached 150 to 
160 upon each attempt. May 29, five and a half months after 
admission, after two preliminary hypodermics of morphin and 
scopolamin, one and two hours respectively before the time of 
operation, the classical local anesthesia injection was made, and a 


246 LOCAL ANESTHESIA IN SURGERY OF THE NECK 


lobectomy was performed, removing f of the gland. The patient’s 
pulse reached 180 during the operation. In twenty-four hours 
it was 160 and in forty-eight hours 120. The patient was dis¬ 
charged from the hospital on June 7, the pulse averaging about 100. 
She has since gained sixty pounds in weight and is in excellent health. 

Note .—During one of the intervals this patient vomited every¬ 
thing she ingested over a period of eleven days. Narco-local anes¬ 
thesia was used in this case during each operative procedure, 
excepting the first, and it was following the first operative pro¬ 
cedure that the method of stealing the operation was first attempted, 
the plan described on page 243 being carried out. 

THE LARYNX. 

Nerve Supply of the Larynx.— The nerve supply of the larynx is 
as follows: The larynx itself is supplied by (1) the internal laryn¬ 
geal branch of the superior laryngeal (vagus), which is distributed 
to the mucous membrane of the larynx and base of the tongue, 
(2) the external branch of the same nerve which is motor and 
supplies the cricothyroideus, (3) the recurrent laryngeal (n. 
recurrens), also of the vagus, which supplies the rest of the laryngeal 
muscles and also sends a few sensory filaments to the laryngeal 
mucosa, and (4) the sympathetics. 

Laryngectomy.— This operation should, it is believed, almost 
always be performed under local anesthesia and in at least two, as 
Crile has so well shown, or perhaps better, three stages. 

Technic of Anesthesia.—In removing this organ it is necessary to 
perform a posterior infiltration block of the cervical nerves (Fig. 
68, page 237). The technic employed for the producing of anes¬ 
thesia is as follows: 

Superficial and Deep Infiltration.—A subdermal wheal is made in 
the midline in front and a subdermal infiltration of sufficient extent 
to allow free elevation of the skin is made (Fig. 80). A vertical 
infiltration block is then made from the upper part of the neck 
downward posterior to the larynx and trachea medial to the large 
vessels, (Fig. 81, A and B; A 1 and B l ). The skin flap is raised and 
the larynx and trachea isolated from the surrounding structures, 
iodoform gauze being packed about these organs and allowed to 
remain. At the second operation a subdermal infiltration of the 
skin may be painlessly made by beginning in the subdermal fat at 
the edge of the wound. Before dividing the trachea a few minims 
of 4 per cent cocain solution should be introduced into it by means 
of a fine needle which passes between the tracheal rings. 

The patient is instructed to hold the breath for a few seconds 
and to avoid coughing if possible. Anesthesia of the tracheal 


THE LARYNX 


247 



Fig. 80. —Laryngectomy. Subdermal infiltration and lines of incision. 



Fig. 81.—Laryngectomy. Deep infiltration (A and B). Insert: A' and B' show 

points of injection. 








248 LOCAL ANESTHESIA IN SURGERY OF THE NECK 


mucous membrane is in this manner easily obtained and prevents the 
distressing symptoms which usually follow the opening of the 
trachea. As the lower end of the larynx is grasped and elevated 
an infiltration may be made along its posterior surface and around 
it at some distance from the tissue which is to be removed. 

This effectually blocks the internal and external branches of the 
superior laryngeal nerve and the recurrent laryngeal nerve and will 
render the removal of the voice box practically painless. The 
cooperation of the patient in such an operation as this is extremely 
desirable. In case the three-stage operation is selected the anes¬ 
thetization of the voice box from within is necessary during its 
removal. 

Cases Nos. 11548 and 13702 are examples of laryngeal polypi with 
tracheotomy and carcinoma of the larynx, both of which describe 
the manner of doing laryngectomy by the use of local anesthesia. 


Report of Case No. 11548. 

C. II., female, aged twenty-three years, referred by Dr. J. D. 
Lewis, entered hospital July 20, 1918. 

History: Tracheotomy had been performed upon this patient 
twenty years previously. She had worn a tracheotomy tube ever 
since. The polypoid growths are now presenting about the trache¬ 
otomy wound, which is low, and are interfering with respiration. It 
was therefore thought advisable to explore the voice box to deter¬ 
mine if an effort could be made to restore the normal canal. 

Diagnosis: Laryngeal polypi; tracheotomy. 

Operation: Laryngotomy, excision of polypi, laryngectomy. 

Anesthesia: Local infiltration block. 

First Operation: Classical infiltration block (Figs. 80 and 81) 
was made. Larynx was opened in the midline in front and a 
number of polypi removed, using scissors, curette and cautery. 
They arose principally from the anterior commissure. An island of 
skin was left between the incision in the larynx and the old opening 
in the trachea. A rubber tube was placed in the larynx and allowed 
to remain. The incision was closed with drainage. The patient 
had relief for some time and could even breathe through the normal 
channels, but within three months the granulation-like masses 
began to appear once more about the tracheal opening and laryn¬ 
gectomy was decided upon. 

Second Operation: October 16,1918. Anesthesia: A wide infiltra¬ 
tion was made, using 90 cc of 0.5 per cent novocain-adrenalin solution. 
The incision was made and the trachea divided just above the 
original tracheotomy wound. The larynx was found greatly 
enlarged and the postlaryngeal area was deeply infiltrated and 


THE LARYNX 


249 



involved the anterior wall of the esophagus, 10 cm. inches of which 


allowed to remain in situ. The wound was drained extensively, 
skin being closed with silkworm sutures. The patient’s pulse and 
color did not change during operation. The anesthesia was ideal. 
1 his patient has remained well to date. Fig. 82 shows the patient 
immediately after the laryngectomy had been performed. 



Fig. 82.—Laryngectomy. Photograph of Case No. 11548, at completion of 

operation. 


Report of Case No. 13702. 


H. J., female, aged fifty-four years, entered hospital March 23, 


1920. 


Diagnosis: Carcinoma of larynx; inferior compartment. 

Operation: Laryngectomy (two stages). 

Anesthesia: Local infiltration. 

History: The patient has had gradually increasing sore throat 
and hoarseness for six months. 

First Operation: March 27, 1920. Exposure of the larynx and 
trachea and insertion of gauze pack. 

Anesthesia Technic: Two preliminary hypodermics, scopolamin 
gr. Yiro an d pantopon gr. J, 60 cc of novocain-adrenalin 0.5 per cent 
were used in making the classical block (Figs. 80 and 81). An exces¬ 
sive amount of thyroid tissue interfered somewhat and a portion 
of the right lobe was excised. The wound was thoroughly packed 
with iodoform gauze. 

Second Operation: Laryngectomy. April 3, 1920. 

Anesthesia: Novocain-adrenalin, infiltration block; external to 
the region of the wound 75 cc of 1 per cent solution were injected. 

The packing was removed and a few drops of 4 per cent cocain 
solution were injected into the trachea by means of a fine needle. 





250 LOCAL ANESTHESIA IN SURGERY OF THE NECK 


The trachea was divided below the larynx and the whole voice box 
removed. There was but slight tracheal irritation on account of the 
action of the cocain. The anesthesia was ideal in every way. The 
patient was able to sit up in bed, her pulse being 100 and 



Fig. 83.—Laryngectomy. Photograph of Case No. 13702, undergoing operation for 

removal of the larynx. 

regular. Nourishment was introduced through an esophageal tube, 
which was allowed to remain in situ. The patient’s pulse reached 
140 at the end of twenty-four hours and she died on the third dav, 
from pneumonia. 

Fig. 83 shows photograph of patient during operation. 










CHAPTER IX. 


local anesthesia in surgery of the breast, 

THORAX AND SPINE. 


SURGERY OF THE BREAST. 

For the purpose of discussion this subject may conveniently 
be divided into the treatment of benign and malignant disease. 

The patient’s position upon the operating table should be as 
comfortable as possible and at the same time the surgeon should 
have every opportunity to work to advantage. 



Fig. 84.—Surgery of the breast, comfort. 


Fig. 84 shows the method usually employed. A lateral tilting 

of the table (page 473) allows both the surgeon and assistants access 

to the field. The arm is comfortable and vet restrained. 

•/ 

Benign Tumors.- Frozen Sections. —Technic of Anesthesia.- 

Tumors which are frankly benign, provided they are superficial, 
may be excised under a direct infiltration, but as the diagnosis is 
often in doubt, the plastic resection is commonly employed. For 
the purpose of excising benign tumors and for removing tissue for 
immediate microscopical examination the method illustrated in 
Fig. 85 is the one of choice. The pectoral fascia is infiltrated so 
as to allow the elevation of the breast to the extent required. 







252 


SURGERY OF THE BREAST, THORAX AND SPINE 


Tumors lying in the lower hall of the breast demand an infiltration 
only as high as the nipple line. Tumors in the upper half demand 
an infiltration similar to that used for simple excision of the breast, 
and this infiltration is made with more facility from above. In 
these cases it is well to carry the needle from the line of infiltration 


which marks the site of the future incision under the skin along the 
outer side of the breast, developing intradermal wheals from below 
(Fig. 31, page 149) at the points where the needle is to be reintro- 



Fig. 85.—Benign tumors of the breast. A. B. Subdermal infiltration, and A', B', 
infiltration block. Insert: Sectional view of same. 


duced (Fig. 85, A and B). Two or three wheals will usually suffice 
for this purpose. Through these wheals the long, fine needle may 
be introduced beneath the pectoral fascia from above and the organ 
quickly isolated from its sensory nerve supply (Fig. 85, A and B). 
In performing the operation one must bear in mind that the attach¬ 
ment of the tissues outside the line of infiltration is not devoid of 
sensation and that if the breast is roughly manipulated the patient 
may be caused pain. It is well to mark the site of the tumor by 
placing a towel clip upon the skin directly over it, and after the 








SURGERY OF THE BREAST 


breast lias been elevated through the incision in the fold below the 
tumor may be identified and gently forced into view by means of 



Fig. 86. —Method of exposing benign tumors of the breast. Towel clip identifies 

tumor. Insert shows sectional view. 



Fig. 87.—Benign tumors of the breast. Photograph of Case No. 13555 during 

operation. Forceps everting tumor. 


the towel clip (Fig. 86). The fact that the patient is not inhaling 
a general anesthetic is of decided advantage in these cases, as the 







254 SURGERY OF THE BREAST , THORAX AND SPINE 


examination of the tumor may thus be made with greater delibera¬ 
tion. Fig. 87 shows K. L. undergoing an operation for the removal 
of a breast tumor of unknown pathology through the Warren 
incision and her case illustrates the technic of removing the breast 
in benign disease which this proved to be. 


Report of Case No. 13555. 

Mrs. K. L., female, aged fifty vears, entered the hospital on 
January lb, 1920. 

Diagnosis: Cystic adenoma of breast. 

Anesthesia: Infiltration along the line of Warren, beneath the 
breast, using 120 cc of a 0.5 of 1 per cent novocain-adrenalin solution. 

Operation: Excision of the right breast. The incision was sub- 
dermal and was carried around one-half the circumference of the 
breast. The breast was then separated from the pectoral fascia 
by introducing solution beneath it, the needle passing through the 
anesthetized area of skin. The breast was dissected upward and 
everted and a portion of the tissue taken for the purpose of making 
frozen sections. A pathological diagnosis of cystic adenoma was 
made by Dr. E. T. Bell. The anesthesia was then completed and 
a subdermal infiltration made outlining the site of the upper incision. 
A transverse incision was made and the breast completely removed. 

Suppurative Mastitis. —Technic of Anesthesia for Drainage.— 
Superficial abscesses in the breast may be opened under local 
infiltration. It is well to make the incision between towel pins 
which elevate the skin and thus avoid pressure upon the deeper 
tissues, which are sensitive. A considerable experience with such 
cases has led the author to believe that no ill effects follow an 
infiltration down to the septic pockets. In many instances multiple 
incisions have been made for the purpose of establishing adequate 
drainage. However, one is confronted in these cases with an 
extremely sensitive inflamed organ and usually a patient who has 
suffered considerably, and here the psychic element becomes an 
important factor. Many of these patients will, therefore, more 
properly fall into the class for gas analgesia. On the other hand, 
chronic suppurations and tuberculous fistuhe demanding radical 
excision lend themselves favorably to a circumferential block about 
the area to be excised. In making this infiltration one should 
introduce the solution well away from the contaminated area and 
the needle point should be carried beneath the pectoral fascia, thus 
practically isolating the breast from its nerve supply. 

Malignant Tumors.—Excision of the Breast.—The nerve supply 
of the skin involved in radical excision of the breast for cancer 
is from (1) nn. supraclaviculares (anterior, middle and posterior) 


SURGERY OF THE BREAST 


255 


(III, I\ ( ), which are distributed to the upper part of the chest, 
shoulder and the region of pectoralis major and the deltoideus 
muscles; (2) the thoracic intercostal nerves (II, III, IV, V, VI, T) 
which give off anterior and lateral cutaneous branches from the 
anterior divisions of the main thoracic nerves and supply the skin 



Fig. 88.—Excision of the breast. Nerve supply of tissues involved. 1, N. 
occipitalis major; 2, N. auricularis magnus; 3, N. vagus; 4, ganglion cervicale 
superius; 5, N. supraclaviculares; 6, N. dorsalis scapulae; 7, N. accessorius; 8, 
N. suprascapularis; 9, N. intracostalis III; 10, Nn. thoracales anteriores; 11, N. 
thoracales longus; 12, N. subscapularis; 13, N. intercostobrachialis; 14, N. thoraco- 
dorsalis; 15, N. axillaris; 16, N. musculocutaneus; 17, N. radialis; 18, N. hypoglossus; 
19, N. laryngeus superior; 20, N. hypoglossus (ramus descendens); 21, ansa hypo- 
glossi; 22, ganglion (cervicale), medium et inferius; 23, N. laryngeus inferior; 24, 
N. recurrens dextra; 25, N. vagus dextra; 26, N. recurrens sinistra; 27, N. vagus 
sinistra; 28, N. intercostalis VI; 29, N. phrenicus; 30, truncus sympatheticus. 


of the thoracic wall and the mamma; (3) the lateral cutaneous 
branch of the second thoracic (intercostobrachial nerve) crosses the 
axilla and supplies the skin of the upper part of the arm adjoining 
the axilla. 

Fig. 88 (also see Fig. 36, page 171) shows the nerves which must 
be blocked in making the radical operation. 














250 SURGERY OF THE BREAST , THORAX AND SPINE 


The pectoralis major and minor muscles and fascia are supplied 
by (1) nn. thoracales anteriores (lateral V, VI, VII C; medial 
VIII, C, I T), which come from the brachial plexus. 

The latissimus dorsalis is supplied by the thoracodorsal nerve 
(n. thoracodorsalis V, VI, VII C), also of the brachial plexus. 

The serratus anterior is supplied by n. thoracalis longus, the 
external respiratory nerve of Bell (V, VI, VII C). 

The deltoideus is supplied by the anterior branch of n. axillaris 
(V, VI C). 

The intercostales, subcostales, levatores costarum and serratus 
posterior are supplied by branches of the upper thoracic intercostal 
nerves. 

In addition to the nerves mentioned, which it will be seen arise 
from the third cervical to the sixth thoracic, there must also be 
considered the main trunks of the brachial plexus, (1) n. ulnaris 
(VIII, C, I T); (2) n. medianus (VI, VII, VIII, C, I T); and (3) 
n. musculocutaneus (V, VI, VII, C) as they pass through the 
axilla in conjunction with the axillary vessels. 

Radical Excision.—Whether the advantages to be derived from 
the use of local anesthesia in these cases in which the diagnosis is 
certain are sufficiently great to offset the disadvantages, such as the 
time required to make the blocking, the discomfort incident to and 
the rather complicated technic involved in making it, is an open 
question. It is an established fact that an excellent anesthesia 
may be produced by the local method. The anesthesia will 
endure sufficiently long to allow of the most painstaking and 
thorough work. The facility for operating is excellent and the 
after-effects are much less disagreeable than when general anesthesia 
has been administered. However, as the majority of patients with 
carcinoma of the breast are fair surgical risks and withstand the 
radical operation well, and as the results even with general anes¬ 
thesia are very good, it is probable that the performance of this 
operation under local anesthesia will remain, for some time at least, 
in the hands of those who may be said to be partial to local anesthesia 
and who are especially familiar with its use. The author’s 
experience is limited to 20 cases, and while appreciating the diffi¬ 
culties which present, he feels that its relative safety makes its 
use desirable in the hands of the surgeon who is familiar with the 
use of local anesthesia. It would seem advisable that the poor 
surgical risks, at least, should be operated upon by this method. 

In performing radical excision of the breast physical comfort 
of the patient’s body assumes considerable importance, as one 
position must be maintained over a comparatively long period. 
The method described on page 251 effectually meets the require¬ 
ments (Fig. 84). 


SURGERY OF THE BREAST 


257 


lechnic of Anesthesia .—It will be seen that one must deal with 
the brachial plexus, the first six or seven thoracic nerves upon the 
side involved, and the intercommunicating nerves down the midline 
in front as they cross over from the opposite side. While formerly 
we depended upon a circumferential infiltration in these cases the 
amount of solution required made it seem advisable to depend 
more upon the regional method. The technic which we have 
employed during the last four years is as follows: Brachial anes¬ 
thesia is established by the method of Kulenkampff (Fig. 30, page 
130). The thoracics from the first to the seventh are blocked 
paravertebrally following the establishment of a subdermal infiltra- 



Fig. 89.—Excision of the breast. A cervical block. Subdermal infiltration made 
from initial wheal in front, preparatory to intercostal block. 


tion (Fig. 89). Approximately 15 cc of a 1 per cent novocain- 
adrenalin solution is injected into the region where each nerve is 
known to lie (Fig. 90), the needle being introduced just below the 
border of the rib, advanced 1 cm. and the solution allowed to flow 
in as the needle is withdrawn, the injection being terminated as the 
needle is retracted to the rib border. The third step in establishing 
anesthesia consists in infiltration of the tissues beginning at the 
center of the sternum above and extending down the midline as 
far as desired (Fig. 91). In beginning this infiltration a long needle 
is introduced through the wheal which has been made for the 
purpose of establishing brachial anesthesia. In this manner ^ 
17 






258 SURGERY OF THE BREAST, THORAX AND SPINE 


subdermal wheal may be established near the suprasternal notch 
and from this point the subdermal infiltration may be carried out. 

The method recommended by Willy Meyer of performing this 
operation from above downward allows one to reach the nerve supply 
early in the operation and to reinforce areas which may have been 



missed in making the original infiltration. Also, the time required 
in making the axillary dissection will permit of the maximum action 
of the anesthetic solution upon the intercostal nerves so that one 
will have the full advantage of the anesthetic in areas supplied by 
these nerves when they are reached. 



























































SURGERY OF THE BREAST 


259 


One should, however, raise all skin flaps as a preliminary measure 
and perhaps even perform the lower part of the dissection before 
dissecting the axilla to avoid the possibility of being compelled to 
reinforce the anesthesia of the intercostals which may disappear 
provided one is too long delayed in carrying out the axillary dis¬ 
section. This embarrassment has befallen the author upon more 
than one occasion. The choice of methods will depend somewhat 
upon one’s speed as an operator. 



Fig. 91 .— Excision of the breast. A, cervical block; B, brachial anesthesia; C, 
subdermal block nerves from opposite side. A otc’ Blocking cervical nerves at A 
renders transverse subdermal infiltration unnecessary. 


Cases No. 9041, 9996 and 14315 are examples of malignant tumors 
of the breast and show the methods of treatment under local 
anesthesia. 

Report of Case No. 9041. 

Mrs. C. D., female, aged fifty years, entered hospital April 30, 
1919. 




260 SURGERY OF THE BREAST, THORAX AND SPINE 


Diagnosis: Carcinoma of the right breast; diabetes inellitus; 
adiposity. 

Operation: Radical excision of breast. 

Anesthesia: Brachial block; local infiltration. 

History: The patient’s weight was 280 pounds. She has just 
passed the menopause. She has had swelling and soreness in right 
breast for several weeks with some yellowish discharge from nipple. 
Her only other complaint was edema of the lower limbs. Patient 
has had diabetes for a number of years and the urine contained a 
large amount of sugar at each examination. She was placed under 
diabetic management. 

Operation May 10, 1919. 

Technic of Anesthesia: Infiltration block preceded by brachial 
anesthesia, 20 cc of 1 per cent novocain-adrenalin solution being 
used. As an intercostal block was not carried out in this case it 
was necessary to reinforce the anesthesia in the axillarv line. Both 
muscles were removed, the total amount of solution reaching 540 cc. 
of 0.5 per cent. (The largest amount ever used by the author.) 

The tumor mass weighed 4J kgm. The wound measured 30 x 40 
cm. A complete dissection of the axilla was made. The patient 
showed no signs of toxicity notwithstanding the large amount 
of solution used and the pulse-rate at the completion of the opera¬ 
tion was 84. 



Fig. 92.—Excision of the breast. Photograph of Case No. 9996 during operation. 


Report of Case No. 9996. 

M. B. S., female, aged forty-nine years, married. 
Diagnosis: Carcinoma of the left breast. 






SURGERY OF THE THORAX 


261 


Operation: Radical removal of the breast, April 2, 1916. 

Anesthesia: Brachial block; intercostal block; circumferential 
infiltration, 0.5 of 1 per cent novocain-adrenalin solution. 

In this case brachial anesthesia was performed and followed by 
a subdermal infiltration, circumscribing the field of operation. The 
intercostals were blocked in the postaxillary line. Anesthesia was 
ideal. The axilla was dissected first and a piece of the serratus 
magnus muscle was sutured over the vessels and nerves. 360 cc of 
solution were used, while in the case of D. II., 240 cc were used, and 
180 cc of a 0.7 per cent novocain-adrenalin solution has answered the 
purpose in a number of cases. Fig. 92 shows the patient undergoing 
operation. 

Report of Case No. 14315. 

D. II., female, aged fifty years, entered hospital December 15, 
1921. 

Diagnosis: Carcinoma of the right breast. 

Operation: Radical excision of the breast. 

Anesthesia: Brachial block, intercostal block, midline infiltration; 
240 cc of 0.7 of 1 per cent of novocain-adrenalin solution. 

Preliminary blocking according to the technic described on page 
257, Figs. 89, 90 and 91, the first to the seventh thoracic nerves 
being blocked. 10 cc of the solution were used in the region of each 
nerve. Brachial anesthesia, midline infiltration. 

A Wolff graft was used to close the skin defect. In this case 
the anesthesia was excellent, although the amount of solution used 
was comparatively small. This technic, which has been applied in 
the last twelve cases, would seem to be the most satisfactory method 
of producing anesthesia for radical amputation of the breast. 

SURGERY OF THE THORAX. 

The Thoracic Nerves.—The thoracic nerves are twelve in number, 
each nerve emerging below the corresponding vertebra and rib. 
Eleven are intercostal, the twelfth lying below the last rib (see 
Plate IX). 

The first thoracic emerges from the spinal canal below the neck 
of the first rib and is divided into two parts. The upper part enters 
into the formation of the brachial plexus and the lower part courses 
forward in the first intercostal space and supplies the upper inter¬ 
costal muscles. 

The second thoracic passes forward in the second intercostal 
space and supplies the muscle and courses forward and supplies 
the skin of the front of the chest over the second intercostal space. 

The third, fourth, fifth and sixth thoracic nerves appear on the 


262 SURGERY OF THE BREAST, THORAX AND SPINE 


posterior wall of the thorax and extend forward between the inter¬ 
costal muscles as far as the middle of the chest wall. At the side of 
the chest wall they pierce the internal intercostal muscles and lie 
upon the pleura and the aponeurosis of the external intercostal 
muscle and end by supplying the skin on the front of the chest 
wall corresponding to the intercostal space to which they belong. 

The seventh, eighth, ninth, tenth and eleventh have the same 
course and communications as the preceding nerves in the thoracic 
wall, but course forward in the abdominal wall and finally reach the 
anterior abdominal wall and become cutaneous by piercing the 
rectus and anterior layer of its sheaths. 

The twelfth thoracic nerve emerges below the last rib and passes 
outward and downward in the posterior abdominal wall beneath 
the psoas muscle, pierces the transversalis muscle, the posterior 
sheath of the rectus, then the anterior sheath and supplies the 
skin. 

As one of the main drawbacks of general anesthesia relates to 
the invitation to lung complications following its use, and as thoracic 
surgery is in the main concerned with disease of these organs or the 
pleural membranes, we have at once a most important reason for 
the substitution of local for general anesthesia whenever it is 
feasible. The sensory nerve supply is so easily reached and the 
landmarks for locating it are so clear that, with the indications and 
contraindications mentioned above, it is surprising that there still 
remains any doubt in the mind of surgeons regarding the choice 
of anesthesia in a large percentage of chest cases. The novice can 
in a few lessons be taught to block the intercostal nerves and the 
blocking of a sufficient number of these will give one anesthesia 
which will allow the performance of almost every variety of opera¬ 
tion which may be required in this region. The lung tissue is not 
sensitive and as the chest wall may be thoroughly anesthetized there 
is almost no limit to the operative procedures which may be carried 
out. 

Thoracentesis.—Anesthesia Technic.—Every case of thoracentesis 
should be preceded by the use of local anesthesia. The initial wheal 
is made over the point where the needle is to be introduced, and the 
path over which the needle is to travel anesthetized by passing a 
needle vertically through the chest wall, injecting as the needle 
advances. As the pleura is approached the needle should be 
advanced slowly and a comparatively large amount of solution 
injected. A larger needle may now be substituted for the fine one 
and aspiration carried out. Should one desire to explore in another 
locality this process may be repeated, the wheal for such exploration 
being made by the subcutaneous method (see Fig. 31, page 149). 
If intercostal drainage only is desired this may usually be carried 


SURGERY OF THE THORAX 


263 


out without reinforcing the anesthesia already established. In 
case immediate operation is decided upon the anesthetic already 
injected reduces the amount needed for this procedure. 

As these patients are apt to be in poor physical condition it is 
well to use special precautions to prevent suffering during the 
introduction of the anesthetic. The injection should be slowly 
made and all lines of incision blocked by a subdermal injection, 
d he method of having the patient inform the surgeon when anes- 



Fig. 93.—Costectomy. A, intercostal block for rib resection. Insert: Sectional 

view of same. 


thesia is established must be discarded. The surgeon must so 
master the technic that he will know that anesthesia precedes his 
surgical work and it should not be necessary to ask the patient 
whether this or that maneuver causes pain. It has long been the 
custom of surgeons to plunge the trocar through the chest wall of 
the helpless patient without regard for his feelings. It is my opinion 
that local anesthesia should precede this operation in all instances. 

Costectomy. —Technic of Anesthesia.—Should rib resection be 
decided upon the following technic is recommended. A sub- 









264 SURGERY OF THE BREAST, THORAX AND SPINE 


dermal infiltration is made along the line of the proposed incision 
and at least three intercostals are blocked well proximal to the 
point of resection. One often builds a transverse wall across the 
line of incision at the proximal end (see Fig. 93). The operation 
can then be carried out exactly as upon the cadaver. There is no 
pain, no hemorrhage, and provided the patient is not coughing 
there is no expulsive effort. It is important to use rib shears of 
adequate power so that the amount of manipulation may be reduced 
to the minimum. The instrument shown in Fig. 22, page 108, has 
been found satisfactory. Its great power makes the cutting off of 
the rib a simple matter and this obviates the necessity of gouging 
and twisting the chest wall. 

The proximal end of the rib should be divided first, otherwise an 
incomplete anesthesia might have to be reinforced twice. It is 
obvious that good anesthesia at the proximal point of resection 
insures good anesthesia at the distal point. 

Empyema. —Negative Pressure.—Just as we find a negative pres¬ 
sure following perfect anesthesia of the abdominal wall do we find 
here also the identical condition. That is, a patient may retain 
the pus in his pleural cavity or expel it at will, provided he is able to 
avoid coughing, and in all of my cases the patients have been able 
to control the cough for a few moments at least. Even in cases with 
a collapse of one lung and the pleural cavity completely filled with 
pus the pleura may be opened with the patient in the proper 
position and the cough may be controlled and no discharge of pus 
take place. The author evacuated as high as four liters of pus in 
the twelve hours succeeding operation in a case in which the radio¬ 
gram taken before the operation showed a total collapse of one side, 
and yet under perfect anesthesia the pleura was opened and the 
fluid was not found to be under pressure. 

In the cases in which a rib resection is made a purse-string suture 
of catgut is usually placed about the proposed line of incision 
through the pleura before opening the latter. A drainage tube is 
held ready for introduction, its outer end being clamped in the jaws 
of an artery forceps. The patient is instructed to breathe carefully 
as the pleura is incised. If these instructions are carried out one 
may note as the pleura is opened the fluid moving with respiration 
and under no pressure. The drainage tube is then quickly intro¬ 
duced and the purse-string suture tied about it. The author has 
carried out this procedure in a comparatively large series of cases 
and believes that with proper technic and under proper conditions 
the above detailed conditions will usually prevail. 

Massive Rib Resections.—Resection of a large area of the chest 
wall may be accomplished under an infiltration block as described 
above (Fig. 94). The operation recommended by Emil Beck, in 


SURGERY OF THE THORAX 


265 


which the pedicle skin flap is used, may be carried out almost ideally 
under an intercostal block, supplemented by a subdermal infiltra¬ 
tion outlining the flaps of skin (Fig. 94). 

Drainage of osteomyelitis, the dissection of fistuke and the 
removal of necrotic segments of rib lend themselves well to the use 
of local anesthesia under the above technic. 



Fig. 94. —Plastic resection of thorax. Subdermal infiltration. Insert: Sec¬ 
tional view of intercostal block. 


Cases No. 11865 and 11027 are examples of empyema and lung 
abscess respectively which were treated surgically under local 
infiltration and paravertebral intercostal block. 

Report of Case No. 11865. 

F. C., male, aged twenty-seven years, entered hospital March 10, 
1918. 
























266 SURGERY OF THE BREAST , THORAX AND SPINE 


Diagnosis: Empyema; followed by persistent sinus. 

Anesthesia: Paravertebral intercostal block. 

Operation: Skin plastic (Emil Beck). 

History: Patient had developed empyema nine months previously. 
Rib resection was performed, and although the patient gradually 
recovered there remained a sinus in the left chest between the ninth 
and tenth ribs in the postaxillary line. The sinus discharged a thin 
seropurulent material, and roentgen rays of the sinus when filled 
with bismuth paste showed its dimensions to be approximately 
10 cm. long and 5 cm in diameter, and to be directed mesially and 
toward the sternum. The patient had had irrigations with Dakin’s 
fluid and had been given repeated injections of Beck’s paste. The 
general condition was fair. 



Fig. 95.—Plastic resection of chest wall. Photograph of Case No. 11865 during 

operation. 

No preliminary hypodermics. An intercostal block with 
novocain-adrenalin from the fifth to the twelfth rib was made. 
The wound was enlarged by the removal of portions of the two 
adjacent ribs and the further removal of the ends of the rib which 
had been formerly excised. The sinus was larger than anticipated 
from the radiograms. It was thoroughly curetted and packed until 
hemorrhage ceased. Two large skin flaps were then dissected from 
the chest wall, one above and one below, and turned into the sinus. 
In three months the sinus ceased discharging and in eight months 
the skin-lined depression had become completely obliterated. 
Eig. 95 shows the patient undergoing Beck’s skin plastic operation. 

Report of Case No. 11027. 

C. R., female, aged nineteen years, pregnant, entered hospital 
January 12, 1918. 

Diagnosis: Pulmonary abscess. 

Operation: Costectomy; drainage and Beck’s plastic. 




SURGERY OF THE SPINE 


267 


Anesthesia: Local infiltration and paravertebral intercostal block. 

History: Radiograms, physical examination and aspiration showed 
the presence of an abscess the size of a fist in the right thoracic 
cavity on a level with the nipple line. 

A rib resection was made under local anesthesia and after evacuat¬ 
ing the cavity the procedure detailed for Case No. 11865 was carried 
out, with the following modifications in technic: As an extensive 
paravertebral anesthesia had not been carried out a subdermal 
infiltration was made outlining the flaps, which were dissected 
up and turned into the cavity. The patient showed no reaction 
from this operation. Twelve days later she went through a normal 
labor, giving birth to a healthy male child and in three months the 
cavity was completely lined with healthy skin. Six months later 
the cavity was completely obliterated. 

The debilitated individuals with tuberculosis, bronchiectasis 
or other conditions demanding massive collapse of the chest wall 
are among those who must urgently demand recourse to local 
anesthesia. It is gratifying to note the trend of opinion among 
those who are doing a large amount of this work. They are, as a 
rule, most partial to the use of local anesthesia. 

SURGERY OF THE SPINE. 

The nerves supplying the structures involved in an operation 
upon the spine are the medial and lateral cutaneous and muscular 
branches of the posterior divisions of the spinal nerves from the 
second cervical to the last sacral inclusively, the coccygeal nerve 
(n. coccygeus) and the recurrent posterior branches of the lateral 
cutaneous branches of the anterior divisions of the thoracic nerves. 

The operations upon the spine are usually considered formidable 
procedures. The position required is such that the administration 
of inhalation anesthesia is more or less awkward. Not infrequently 
these patients are poor surgical risks, and it would seem therefore 
that local anesthesia would be desirable for work in this region, 
provided it could be used with satisfaction. The spine is extremely 
deeply situated, except at its extremities. Rather large amounts 
of anesthesia are necessary and the spinal membranes are very 
sensitive. The blocking of the nerve supply to the spinal column 
is readily made and there is no great difficulty in exposing the cord 
under local anesthesia. However, in attempts to remove tumors 
connected with the dura extreme pain was experienced and in one 
case the use of ether became necessary. No attempt was made to 
infiltrate the membranes themselves, though it would seem that 
this might easily be done through a fine needle and that infiltration 
would probably do no permanent damage. One would, of course, 


268 SURGERY OF THE BREAST, THORAX AND SPINE 


be compelled to use extreme care in order to avoid the introduction 
of the solution in the canal where it might be carried to the brain. 
The author’s experience in surgery of the spine is so limited that 
he has had little opportunity to test these points. A number 
of surgeons have reported operations under local anesthesia and 
their reports are so optimistic that one wonders why those who 



Fig. 96.—Laminectomy. A, subdermal infiltration and infiltration block. Insert: 

B B, sectional view of same. 


have abundant material do not further develop the method. This 
field offers a favorable ground for research. 

Technic of Anesthesia.—A subdermal infiltration is made on either 
side of the spine, 5 cm. from the midline, and through these lines the 
deep injection is made as indicated in Fig. 96. After the exposure 
has been effected, the anesthesia may be reinforced between the 







SURGERY OF THE SPINE 


269 


transverse processes if required. The bony structures may be 
removed by forceps or with a chisel, but, as stated above, the 
membranes are extremely sensitive. If during the manipulation 
one should happen to come in contact with unblocked spinal nerves, 
the patient is apt to complain of very disagreeable sensations. 
With any technic so far described the whole operation cannot, 
with certainty, be painlessly performed under local anesthesia 
alone. Possibly the most desirable method would be to admin¬ 
ister a small amount of nitrous oxide or ether during the time 
that the cord and its numerous nerves are to be manipulated. The 
rest of the work is perfectly feasible under local anesthesia. The 
exploration of fracture cases and the removal of foreign bodies are 
accomplished with comparative ease. 

Cases No. 9202 and 12024 are examples of spinal cord tumors, the 
former of which was removed under local infiltration block alone and 
the latter requiring inhalations of ether for but a few minutes. 


Report of Case No. 9202. 

P. H. B., female, aged fifty years, married, entered hospital 
June 28, 1916. 

Diagnosis: Tumor of the spinal cord; recurrent. 

Operation: Excision of the tumor, July 1, 1916. (Patient had 
been operated upon seven years before for a spinal cord tumor in 
the same location.) 

Preliminary Medication: She was given two preliminary hypo¬ 
dermics, | gr. pantopon and yij-o gr* scopolamin. 

Anesthesia: Local infiltration block. 

Infiltration was made from the first cervical vertebra to the 
fifth dorsal. 4 he arch and lamina of the seventh cervical vertebra 
were removed, several laminae below this having been removed at 
the previous operation. The dura was exposed at the lower end of 
the incision, and in this manner the scar tissue was easily separated 
from the cord, and without special complaint on the part of the 
patient. A tumor was found beneath the dura on the right side of 
the cord, at about the center of the incision. The tumor extended 
around to the front, apparently perforating the dura, and was 
intimately connected with the vertebral wall. As the growth 
infiltrated the bone complete removal could not be accomplished. 
The only painful sensations complained of by the patient were 
referred to the region of the arm, which was described as a stinging 
pain and a feeling of numbness. Curettage of the body of the 
vertebra was painless, 



270 SURGERY OF THE BREAST , THORAX AND SPINE 


Report of Case No. 12024. 

P. B. S., female, aged thirty years, married, entered hospital, 
May 15, 1919. 

Diagnosis: Spinal cord tumor, in the region of the sixth dorsal 
vertebra. 

Operation: Laminectomy; excision of tumor, May 17, 1919. 

Preliminary Medication: Given a hypodermic of J gr. pantopon 
and -giro & r - stable scopolamin, two hours before operation. This 
dose repeated one hour later. 

Anesthesia: Local infiltration. 150 cc of a 0.5 of 1 per cent 
novocain-adrenalin solution was used, extending from the fifth to 
the tenth dorsal vertebrae. 

The spinous processes were clipped away, without pain, and the 
lamina of the sixth, seventh, eight and ninth vertebrae were removed 
with rongeurs. Exposure of the dura was made without pain. 
However, the incision of the dura caused the patient to cry out. 
A tumor about 3 cm. long and 3 cm. wide was removed from beneath 
the dura after giving the patient a few inhalations of ether, as the 
slightest manipulation of the growth caused the patient the most 
excruciating pain. The cord was found to be markedly compressed, 
and although this patient made a good operative recovery, removal 
of the tumor gave no relief from symptoms. 


CHAPTER X. 


LOCAL ANESTHESIA IN SURGERY OF THE 

EXTREMITIES. 

GENERAL CONSIDERATIONS. 

Advantages of Local Anesthesia in Fluoroscopic and Radiographic 
Examinations.—When using general anesthesia for the reduction 
of fractures it is not an uncommon occurrence for the surgeon to 
be compelled to repeat his manipulations or to make further attempts 
at reduction after the patient has recovered from the anesthetic. 
As it is often considered undesirable to continue general anesthesia 
over an extended period, any delay in the developing of radio¬ 
grams may interfere with proper completion of the reduction. 
Under local anesthesia these conditions do not obtain. 

With the conscious patient fractures may be examined under 
the fluoroscope or radiographed at will even without the aid of a 
portable radiographic apparatus with much less difficulty than 
is the case when the patient is under general anesthesia. The 
fact that local anesthesia continues from one and a half to two 
hours gives an opportunity for repeated examinations and, if 
necessary, repeated attempts at reduction. This is one of the 
most important and satisfactory attributes of local anesthesia 
when employed in this field. 

When reductions of the upper extremities are to be made there 
is the added advantage that the patient is able to transport himself 
from the surgery to the roentgen-ray department and back to bed, 
eliminating much lifting during the various procedures and actually 
helping, in many instances, during the treatment by steadying 
his body and keeping his position in the chair or on the table and, 
later, by holding padding and cast material in place. 

Local Anesthesia of the Hands and Feet.—In producing local 
anesthesia in the hands and feet certain well-established principles 
should be followed. It is well known that the integument upon 
the palms of the hands and the soles of the feet is not only extremely 
thick and leathery , making it difficult for one to pass the needle, 
but that these surfaces are highly sensitive as well. One should 
therefore begin the anesthetization of these regions upon the 
dorsal surface. The initial wheal should always be made upon 
the dorsal surface of the hands or feet and through this wheal the 


272 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


needle may be advanced in any direction between the bones toward 
the plantar surface, the skin of the plantar surface being anesthetized 
from within. As the needle impinges upon the skin the injection 
should be continued with some force until the needle has traversed 
the skin and the point has come into view. 

Nothing will destroy the poise of a patient so quickly as repeated 
needle pricks upon the unanesthetized skin of the palmar surface 
of the hand or fingers or upon the sole of the foot. Even though 
the whole operation is to be made upon the plantar surface the 
needle point should approach from the opposite side and anes¬ 
thesia established in the manner described above. 

The hand and foot may be anesthetized by an infiltration block 
at the wrist or ankle joint respectively. The location of the nerves 
in this region is superficial, and they are easily reached by the 
injecting needle. The ulnar, median and radial may be anesthetized 
with great precision, as may also the terminal branches of the 
tibial, common peroneal and femoral. (Plates VI and XI.) 

Local Anesthesia of the Fingers and Toes.—In anesthetizing the 
fingers and toes an infiltration block is all that is necessary. As 
the nerves run upon the lateral aspect of the digits the solution 
may be introduced in more liberal quantities in these regions. 
However, it requires but a moment to thoroughly infiltrate the 
soft tissues at the bases of the fingers and toes and there is no 
margin of error in the resulting anesthesia. Special refinements 
in technic, such as attempts to accurately locate the nerve trunks, 
are unnecessary. An infiltration block gives the most excellent 
result that it is possible to obtain. If more than one digit is to 
be anesthetized the needle may be carried subderm ally from one 
base to the next. All secondary intradermal wheals should be 
made from beneath (see page 149, Fig. 31). 

Infiltration or infiltration block may be used in the removal of 
growths or in doing plastic operations upon the extremities. In 
many cases interruption of the entire sensory nerve supply is 
unnecessary and a local block may be used here as in other regions 
of the bodv. 

t/ 

As an example of the application of the infiltration method as 
well as the use of local anesthesia in children the following case 
is of interest: 


Report of Case No. 10047. 

Iv. M., aged eight years, entered the hospital September 3, 1917, 
referred by Dr. George Walker. 

Diagnosis: Hemangioma of right arm. 

Operation: Excision of the tumor. 

Technic of Anesthesia: Local infiltration, 


GENERAL CON SI DER A TIONS 


273 


History: Since birth the patient had presented a tumor on the 
anterior aspect of the right arm. The tumor was approximately 



Fig. 97.—Tumor of arm. (Hemangioma.) Photograph of Case No. 10047, before 

operation. 



Fig. 98. —Tumor of arm. Photograph of Case No. 10047, during operation for 

excision of tumor. 


20 cm. in length and 8 cm. in width, and fluctuated. The aspirated 
fluid was reddish and showed 50,000 red blood cells per cubic milli¬ 
meter. 

18 







274 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


A circular infiltration block was made above the tumor, the 
needle being introduced directly toward the humerus until the 



Fig. 99. —Transverse infiltration block of arm and forearm. 1, N. cutaneus anti- 
brachii dorsalis; 2, N. radialis; 3, N. cutaneus antibrachii lateralis; 4, N. medianus; 

5, radius; 6, N. radialis; 7, N. cutaneus antibrachii lateralis; 8, humerus; 9, N. ulnaris; 
10, N. cutaneus antibrachii medialis (ramus ulnar); 11, N. cutaneus antibrachii 
medialis (ramus volar); 12, N. interosseus antibrachii volaris; 13, N. ulnaris; 14, N. 
medianus; 15, N. cutaneous antibrachii medialis (ramus volar). 

Fig. 100.—Transverse infiltration block of thigh and leg. 1, femur; 2, fibula; 
3, tibia; 4, N. cutaneus femoris posterior; 5, N. ischiadicus et peroneus communis; 

6, N. femoralis; 7, N. saphenus; 8, N. suralis; 9, N. tibialis; 10, N. saphenus; 11, N, 
peroneus profundus, 






















GENERAL CONSIDERATIONS 


275 


growth was practically isolated from its nerve supply, 120 cc of 
0.5 of 1 per cent novocain-adrenalin solution being used. An 
incision 20 cm. long was made and the tumor dissected out. It 
arose from the attachment of the deltoid to the humerus in front 
of the biceps, from which it could be peeled, but its attachment to 
the deltoid was so intimate that a portion of this muscle had to 
be removed with the tumor. 


; 



Fig. 101. —Transverse infiltra¬ 
tion block of thigh. A, B and 
C, subdermal infiltration. (An¬ 
terior view.) 



Fig. 102. —Transverse infiltration 
block of thigh. B, C, D and E, 
subdermal infiltration. (Lateral 
view.) 


Note .—This child laughed throughout his operation and enjoyed 
every moment of it. When I pricked him with the needle in 
administering the anesthetic and apologized by saying, “Excuse 
me,” he responded, “You’re excusing yourself altogether too 
much.” 

Figs. 97 and 98 before and during the operation show the extent 
of the tumor and also the mental attitude of the child. 

Transverse Infiltration Block.—If, for any reason, regional, 
venous or arterial anesthesia are contraindicated transverse infil¬ 
tration block may be used when operating upon the extremities. 





276 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


Fig. 99 illustrates the manner of making the infiltration block—a cir¬ 
cular strip of skin is anesthetized by the method described (Fig. 31, 
A, B, C, page 149). The needle point is then carried down to the 
region where the sensory nerve trunks are known to lie. 

As a rule it is well to establish the infiltration block from 7 to 
15 cm. proximal to the site of operation. 

In case one is concerned regarding the question of toxicity, a 
constrictor may be applied. Conversely, should a tourniquet 
be used, the question of toxicity is thereby automatically eliminated. 
In removing the constrictor some care is necessary. The removal 
should be gradual. As a rule the longer the time between the 
making of thei nfiltration and the removal of the constrictor the 
less will be the liability to toxic absorption of the anesthetic solution. 



Fig. 103.—Transverse infiltration block of thigh. A, B, C, D and E, subdermal 
infiltration. (Sectional view showing infiltration block of the main nerve trunks.) 
1, N. femoralis; 2, N. saphenus; 3, femur; 4, N. ischiadicus et peroneus communis; 5, 
N. cutaneus femoris posterior. 


Fig. 100 shows the application of the principle of infiltration 
block to the lower extremity. 

KJ 

Fig. 101 shows the subdermal infiltration of the thigh and illus¬ 
trates the manner in which this may be painlessly done. 

Fig. 102 is a continuation of the subdermal infiltration. 

Fig. 103 shows the infiltration block in the region of the large 


O 

nerves 


THE REDUCTION OF FRACTURES AND DISLOCATIONS. 

Fractures of either the upper or lower extremities may be reduced 
by either the closed or open method under local anesthesia. In 
case the patient will cooperate brachial anesthesia can be estab- 







THE REDUCTION OF FRACTURES AND DISLOCATIONS 277 

lished and any fracture or dislocation of the upper extremities may 
be treated (Fig. 30, page 130). Cases No. 9374, 8850 and 14154 are 
examples of fractures of the upper extremity which were treated 
surgically under local anesthesia. 


Report of Case No. 8850. 

M. S. C., male, aged sixteen years, entered hospital November 
26, 1915. 

Diagnosis: Fracture-dislocation of the shoulder-joint. 

Operation: Open operation and reduction of fracture and fixation 
of fragments. 



Fig. 104.—Fracture-dislocation of the shoulder joint. Roentgenograph of Case 

No. 8850, after operation. 


Anesthesia: Brachial block 10 cc, 2 per cent novocain-adrenalin 
solution and local infiltration 60 cc of 1 per cent novocain solution. 

History: Two months previously the patient was thrown from 
an automobile, injuring his shoulder-joint. Effort had been made 
to reduce the dislocation, roentgen rays had not been taken and he 
entered the hospital because of limitation of motion of the arm. 

Anesthesia Technic: The brachial plexus was blocked and a 
subdermal infiltration was made along the proposed line of incision 
which was over the anterior portion of the deltoid. The anesthesia 
was absolute. The deltoid was split and the head of the humerus 
was reduced into its socket. The humeral shaft was adjusted to 
the head and a screw inserted diagonally through the shaft and into 
the head of the bone. Fig. 104 shows the roentgenograms after the 
operation. 




278 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


The Reduction of Fractures and Dislocations in Children.— In 

case the cooperation of the patient cannot be obtained we have 
not attempted the reduction of fractures or dislocations of the 
humerus or shoulder-joint respectively, nor the elbow-joint in 
young children. Below the elbow-joint the infiltration block is 
efficient (Fig. 99, page 274) and the child may be restrained, if need 
be, while the infiltration block is being made. Case No. 14154 
illustrates some points of advantage of the method. 

The following case will illustrate the application of brachial 
anesthesia in fractures of the forearm: 



Fig. 105.—Colies’s fracture, brachial anesthesia. Photograph of Case No. 9374, 

directly after reduction of fracture. 


Report of Case No. 9374. 

A. B. D., aged twenty-eight years, entered the hospital, November 
3, 1916. 

Diagnosis: Fracture of the lower third of the left radius. 

Brachial Anesthesia: 5 cc of 2 per cent novocain solution were 
used and anesthesia was complete in five minutes. 

Operation: Relaxation was perfect, the fracture reduced and 
moulded splints applied without pain to the patient. 

Fig. 105 shows patient immediately after reduction and appli¬ 
cation of moulded splints. 






THE REDUCTION OF FRACTURES AND DISLOCATIONS 279 

Report of Case No. 14154. 

E. K. M., aged twelve years, entered office on February 20, 1921. 

Diagnosis: Fracture of the right radius and ulna. (Figs. 106 
and 107.) 

Operation: Reduction of fracture—closed method. (Figs. 108 
and 109.) 

Anesthesia: Transverse infiltration block; 40 cc of 1 per cent 
novocain-adrenalin solution being used. 



Fig. 106.—Anteroposterior view. 



Fig. 107.—Lateral view. 

Figs. 106 and 107.—Fracture of radius and ulna. Roentgenogram of Case 

No. 14154, taken before reduction. 


History: Boy fell, striking on right hand, fracturing wrist. 
Roentgenogram showed a transverse fracture of both radius and 
ulna about 5 cm. above the wrist joint. A transverse block was 
immediately made at a point 5 cm. above the line of fracture. The 
fractures were reduced—a moulded plaster splint was applied and 
the boy allowed to return home on the street car with his mother. 







280 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


Note .—This case is mentioned to illustrate certain points. The 
child’s mother was a widow without funds. The child came to 
the office during office hours on a busy afternoon. The necessity 
of preparing him for general anesthesia, as well as the necessity 
of employing an anesthetist or sending the child to the hospital, 
the amount of time required in order to carry out the necessary 
treatment were factors which entered into the handling of the 



Fig. 108 



Fig. 109 

Figs. 108 and 109. —Fracture of radius and ulna. Roentgenogram of Case No. 
14154, taken directly after reduction under transverse infiltration block. 


case. Under the plan mentioned above an assistant anesthetized 
the arm, the author reduced the fracture, the technician made the 
roentgenograms, and the assistant then applied the necessary 
dressing. The total expenditure of time by the author was less 
than five minutes. Furthermore, the child left the office travel¬ 
ing on his own power before the close of office hours. From an 
economic standpoint the use of local anesthesia in such a case 
presents many advantages. 








THE REDUCTION OF FRACTURES AND DISLOCATIONS 281 


The Reduction of Malunited Fractures in Children.— The 

author has operated upon a number of fractures of the femur in 
children under twelve years of age and finds that they lend them¬ 
selves especially well to local anesthesia and come through the 
operation in much better condition, as a rule, than when general 
anesthesia is administered. The following cases will illustrate 
the application of the method. 


Report of Case No. 9774. 

F. 1). A., female, aged twelve years, entered hospital June 17, 
1916. 

Diagnosis: Fracture of femur; malunion; malposition. 

Operation: Reduction with Gratton osteoclast, seven weeks 
after injury. 

Anesthesia: Local infiltration block, 7 cm. above the point of 
fracture. 90 cc of 0.5 per cent novocain-adrenalin solution were 
used. 



Fig. 110.—Fracture of the femur in children. Photograph of Case No. 9774, 
taken during reduction of malunited fracture of the femur. Gratton osteoclast in 
action. 


The child’s limb was small, and, therefore, but a moderate 
amount of solution was required. The thigh was heavily padded 
with felt and the Gratton instrument applied (see Fig. 110). The 
bone was refractured and the result checked up by roentgenograms 
before the removal of the Gratton instrument. This child had no 
pain at the point of fracture, but complained moderately of the 
stretching of the muscles, which gave some distress in the region 
of the knee joint. However, the anesthesia was entirely satis¬ 
factory and the child partook of a hearty meal while the plaster 
cast was being trimmed. 




282 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


Fig. 110 shows a photograph made during the reduction with 
the Gratton osteoclast in action. 

Our youngest case was a boy, aged seven years, who submitted 
to an open operation for the reduction of mahmited fracture of 
the femur about nine weeks after the accident. He was bribed 
into avoiding the shedding of tears, by a gift of five silver dollars. 

Report of Case No. 14118. 

11. M. C., aged seven years, male, entered hospital on January 
26, 1921. 

Diagnosis: Fracture of right femur at junction of upper and 
middle third. 

Operation: Open reduction of fracture. 

Anesthesia: Transverse local infiltration block, using 120 cc of 1 
per cent novocain-adrenalin solution. 

History: The patient was struck by an automobile two days 
before entering the hospital and coming under the care of the 
author. On first entering the hospital, Buck’s extension was 
applied with leg in vertical position. The patient was irrational 
and was handled with difficulty. The Buck’s extension was 
substituted by a Thomas splint, as the fracture was oblique and 
complete reduction could not be brought about. The boy con¬ 
tinued irrational and was restrained with difficulty, and it was 
assumed that he had sustained a brain injury. It was found impos¬ 
sible to overcome the fracture by extension, and an open operation 
was decided upon as soon as the mental condition improved. 

Two weeks after the accident a local infiltration was made along 
the outer aspect of the thigh and a deep circular block was made 
on a line just below the great trochanter/ (Fig. 101, page 275.) 
Through a 15 cm. incision the fragments were exposed and the 
bone ends were turned out, freshened and reduction made, the 
fragments being held in place by a heavy wire suture. 

The patient became somewhat pale at the end of the operation, 
which required one and a half hours, although there was but slight 
loss of blood. He was given $5.00 as a bribe and went through 
the operation without crying. 

Note.—This patient, while showing some reaction, returned to 
bed in better condition than has usually been the case with this 
type of operation. Prompt union followed. 


BONE TRANSPLANTS 


283 


BONE TRANSPLANTS. 

The transfer of bone grafts may be accomplished under local 
anesthesia quite as easily as may be the open reduction of fractures. 
In addition to the establishment of anesthesia at the point of 
fracture, it is necessary to anesthetize the area from which the 
transplant is to be obtained. In case the rib is to be used, the 
technic employed in Chapter IX, page 263, is to be recommended. 
As most bone transplants are obtained from the anterior surface 
of the tibia and the blocking of this region is so simple, the pro¬ 
cedure presents little difficulty. 

Technic of Anesthesia.— A subdermal infiltration may be made 
along the line of the proposed incision, and through this the needle 
point may be carried alternately from one border of the tibia to 
the other subdermally. The infiltration should be carried well 
above the upper end of the position of the transplant, and at this 
point the needle should be introduced posterior to the tibia and 
a liberal amount deposited. 

An equally satisfactory procedure is the establishment of a rhom¬ 
boid infiltration over the area from which the transplant is to be 
removed, the lateral boundaries of the rhomboid corresponding to the 
external and internal borders of the tibia. Through this subdermal 
infiltration area, the needle may be introduced verticallv until it 
reaches the periosteum and the site of the transplant isolated. 

No attempt should be made to introduce the solution subperios- 
teally. Cases Nos. 8674 and 8338 are examples of bone trans¬ 
plants done under local infiltration and infiltration block. 

Record of Case No. 8338. 

Mrs. C. C. I)., aged fifty years, entered hospital January 5, 1915. 

Diagnosis: Giant-cell sarcoma of distal end of right ulna. 

Operation: Excision of tumor and bone transplant from tibia. 

Anesthesia: Brachial block; local infiltration on leg. 

History: The patient complained of numbness in both wrists. 
An aching pain developed in the right wrist, which began to swell 
five months ago. The swelling was most marked over the ulnar 
surface and the other joints were normal. 

Roentgen rays showed rarefaction of ends of metacarpals and 
phalanges with an enlargement of distal end of ulna, which was 
extremely rarefied and trabeculated. (See Fig. 111.) 

Anesthetic arid Operative Technic: Brachial block was done with 
the patient in a reclining position and 20 cc of 2 per cent novocain- 
adrenalin solution were used. 

A circumferential block of Hackenbruch using 0.5 per cent of 


284 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


novocain-adrenalin was made over the anterior surface of the right 
leg outlining the bone segment to be removed from the tibia. 

During this time the brachial anesthesia had become established 
and an incision from the middle of the forearm to about 5 cm. 
below the styloid process was made. The ulna was freed and about 
8 cm. of its distal end was resected. 

A transplant was next removed from the tibia and modelled 
to articulate with the carpal joint, after which the small end was 
driven into a drill hole in the ulnar fragment to hold it in place. 
(See Fig. 112 A.) 

Note .—The only unpleasant sensation throughout the operation 
occurred when the saw plunged deeply into the marrow of the tibia. 



Fig. 111. Roentgenogram of Case No. 8838, before operation, showing both 

normal and abnormal wrist. 


Report of Case No. 8674. 

H. C. A. aged twenty-seven years, entered hospital January 30 
1915. 

Diagnosis: Ununited fracture of the right radius and ulna at 
the midpoint. 

Operation: Intramedullary autotransplant. 

Anesthesia: Brachial block, 10 cc of 2 per cent novocain-adrenalin 
solution; local infiltration for removal of graft. 

History: Four months previously the patient had been thrown 
from a buggy, breaking both bones of the forearm. Board splints 
and plaster casts had been applied, but the bones had failed to heal 
and patient had presented himself to Dr. Knut Iloegh for exami- 






A 


B 





C D 

Fig. 112.—Roentgenogram of Case No. 8838. A. Immediately after operation; B, 
taken one month after operation; C and D, taken fifteen months after operation. 








286 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


nation, through the courtesy of whom the author was allowed the 
privilege of performing the operation. 

Operation: The patient was given \ gr. morphin and y^- scopol- 
amin at 9 a.m. on February 2, 1915. At 10 a.m. the operation 
was performed. Brachial anesthesia was established with the 
patient sitting in a chair, 10 cc of 2 per cent novocain-adrenalin 
being used. A large rhomboid infiltration was then made on the 
anterior surface of the leg. The site of the fractures was then 
reached by two incisions and the ends of the bones freshened. 
With a large drill the marrow cavity was reamed out and dowels 
were prepared from bone removed from the tibia. These dowels 
were fitted into place, the wound sutured and the patient made 
an uneventful recovery. 

Note. —The anesthesia for the removal of the transplant was 
obtained by a subdermal infiltration of the leg and in addition the 
needle was carried down to the periosteum, making an infiltration 
along the line which marked the line of the transplant to be removed. 


AMPUTATIONS. 

The condition of patients requiring major amputations is usually 
such that the use of local anesthesia is especially desirable. All 
large nerve trunks should be injected with absolute alcohol for 
the purpose of preventing pain and the development of neuromata. 

Technic of Anesthesia. —The technic to be employed for the 
amputation of the upper or lower extremity will depend upon 
circumstances. 

The Upper Extremities.— In the upper extremity brachial anes¬ 
thesia or the venous anesthesia of Bier are the methods of choice, 
although in amputations below the elbow infiltration block pre¬ 
sents many advantages. It is unnecessary to prepare the skin 
in other fields. Transverse block presents no margin of error and 
toxicity may be absolutely eliminated by the use of the tourniquet. 
The method is especially simple and efficient in thin individuals 
where the nerves may be easily located. But a small amount of 
solution is required and with the use of the tourniquet the amount 
administered becomes relatively unimportant. 

Venous anesthesia (see page 112) is efficient for amputation 
below the upper third of the humerus. The technic of its establish¬ 
ment, while comparatively simple, is rather more complicated 
than the other methods. In septic cases it should not be employed. 

Amputation at or near the shoulder-joint demands brachial 
anesthesia with the addition of a subdermal infiltration along the 
lines of incision, as shown in case No, 7610. 



AMPUTATIONS 


287 


Report of Case No. 7610. 

K. C. J., male, aged nineteen years, entered hospital November 
12, 1914. 

Diagnosis: Crushing injury to arm. 

Operation: Amputation of left arm. 

Anesthesia: Brachial block. 

History: The left arm had been cut in a corn shredder twenty- 
four hours previously. The physicians in the country had cut 
away the loose tissue, leaving a considerable amount of bruised 
skin and muscle. After rest and the application of moist dressings 
for a period of eight days there was a line of demarcation indicating 
that the stump, which was 20 cm. in length, would have to be 
reduced to 10 cm. in order to obtain healthy skin flaps. 

Brachial Anesthesia: 10 ec of a 2 per cent novocain-adrenalin 
solution were injected into the brachial plexus, after paresthesia 
of the nerves had been excited by the needle point. The anesthesia 
of the skin and other tissue was good but it was necessary thoroughly 
to anesthetize each of the large nerves as they were exposed before 
severing them. 

The Lower Extremities.— Amputation at or below the hip is best 
performed under infiltration block or direct infiltration, preferably, 
however, under a combination of the two. (See Figs. 101, 102, 
103, page 275.) Venous anesthesia may be used and it presents 
decided advantages in certain cases (page 112.) Regional anesthesia 
also has points of advantage in this field. 

In amputations above the knee one can depend upon an infil¬ 
tration block, combined with local infiltration along the lines of 
incision and a reinforcement by the means of a concentrated solution 
(4 per cent procain-adrenalin) in the large nerve trunks as they 
appear. 

As one approaches the ankle, say in the lower half of the leg, 
an infiltration block (see Fig. 100, page 274) is efficient and the 
rules laid down for amputations of the arm apply. (Fig. 99, page 
274.) Cases Nos. 13712 and 12198 involved amputations of the 
leg, which were done under transverse infiltration block. 

Report of Case No. 13712. 

In the aged or debilitated, local anesthesia is especially desirable. 

Mrs. A. C. I)., aged eighty-five years, entered hospital March 
29, 1920. 

Diagnosis: Gangrene of right foot (senile). 

Operation: Amputation of leg. 

Anesthesia: Transverse infiltration block. 


288 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


Technic of Anesthesia: A transverse infiltration block was made 
12 cm. below the knee, including a subdermal infiltration along 
the line of incision (Fig. 100, page 274), and 90 cc of 0.7 of 1 per 
cent novocain-adrenalin was used. The endosteum was the only 
tissue found to be sensitive throughout the operation. The patient 
made a rapid recovery and was discharged from the hospital in 
two weeks. Fig. 113 shows the patient during the operation. 



Fig. 113.—Amputation of the leg. (Senile gangrene.) Photograph of Case 

No. 13712, during operation. 


Report of Case No. 12198. 

Mrs. H. J. 1)., aged seventy years, entered hospital August 5, 
1919. 

Diagnosis: Varicose ulcer of leg with malignant degeneration. 

Operation: Amputation of leg. 

Anesthesia: Transverse infiltration block. 

History: Patient had varicose ulcers of leg for fifteen years. 
Varicose veins for thirty years. Three months ago an ulcerated 
area became angry in appearance and the leg increased in size. 

Technic of Anesthesia: k transverse infiltration block below 
knee joint was made (Fig. 100, page 274), using 90 cc of 0.7 per cent 
novocain-adrenalin solution. 

Amputation at upper third of the leg. The operation was 
entirely painless and the patient’s condition was without change. 







SUPPURATIVE ARTHRITIS 


289 


Primary healing resulted and the patient left the hospital twelve 
days later. 

Amputation of the thigh, when local infiltration is used, should 
be made by beginning the incision in front, shaping the anterior 
or external flap as the case may be and carefully dividing the 
respective muscles as they appear, watching constantly for the 
sharp contraction which indicates that the nerve supply has not 
been interrupted. Infiltration should be used freely as the ampu¬ 
tation proceeds, provided the indications arise. As the femur is 
exposed the anesthesia may once more be reinforced directly 
under the vision, the needle being carried behind the femur and the 
solution liberally injected. The bone should be sawed in two 
before the posterior flap is made. As soon as the femur has been 
divided the sciatic nerve may be carefully exposed and well blocked 
proximally, using about 5 cc of a 4 per cent novocain-adrenalin 
solution. A few minutes should be allowed to elapse after this 
blocking before the sciatic is divided. In the meantime the tissues 
laterally may be divided and as soon as the sciatic is divided the 
posterior flap may be outlined. When the operation is carried 
on in this manner anesthesia is easily obtained and an excellent 
opportunity for obtaining hemostasis is offered. 

SUPPURATIVE ARTHRITIS. 

Technic of Anesthesia for Drainage.— Suppurative processes in 
and about any of the larger joints may be attacked, incised and 
drained under direct infiltration, omitting the circuminjection 
described for aseptic operations. Liberal incisions are desirable 
and a good exposure is essential, provided there is any doubt regard¬ 
ing the location of the abscess. We have made openings and 
counter openings in a number of cases upon individuals who were 
extremely ill, and in no instance have we seen any untoward local 
effect from the infiltration. Case No. 12491, which follows, illus¬ 
trates drainage of a suppurative hip under local infiltration anes¬ 
thesia. 

Report of Case No. 12491. 

Mrs. E. C. II., aged forty-five years, entered hospital December 
18, 1919. 

Diagnosis: Septic arthritis of left hip. 

Operation: Arthrotomy and drainage. 

Anesthesia: Local infiltration, 180 cc of 0.5 per cent novocain- 
adrenalin solution. 

Operation: Patient was given an injection of scopolamin ^aa 
gr. and pantopon J gr. two hours before operation and one liopr 
19 


290 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


before. Infiltration was made along the lateral aspect of the 
thigh and a longitudinal incision was made down to the abscess 
cavity. 500 cc of creamy pus escaped—the finger was introduced 
and the hip-joint was explored. A long, curved forceps was intro¬ 
duced and after infiltrating the gluteal region an incision was 
made down to the forceps. Dakin’s tubes were introduced through 
the counter opening and passive motion was carried out daily. 
The patient was discharged from the hospital with a movable hip 
on February 8, 1920. 

OSTEOMYELITIS. 

Acute Osteomyelitis.—Technic of Anesthesia for Drainage. 

Osteomyelitis of the acute type demanding only incision and 
drainage lends itself especially well to the use of local anesthesia. 

In cases where the disease has advanced beyond the bony con¬ 
fines the production of anesthesia is similar to that described 
elsewhere for the opening of abscesses. A small infiltration of 
the skin and tissues overlying the abscess is all that is required. 

Direct infiltration of the tissues should be made, the needle 
being carried directly to the bone, provided the latter is to be tre¬ 
phined. The trephining of the bone should be made with a drill, 
as the use of the mallet and gouge is apt to cause the patient more 
or less pain. 

Chronic Osteomyelitis.— In chronic osteomyelitis the infiltration 
should be sufficiently extensive so that any operative procedure 
required may be carried out. As a rule an infiltration block placed 
5 to 7 cm. proximal to the upper limit of the lesion will bring about 
sufficient anesthesia to allow the removal of sequestrse and the per¬ 
formance of curettage or any other necessary procedure. 

Provided one desires to make the implantation of pedicle flaps 
according to the method of Emil Beck, it is necessary only to out¬ 
line such flaps by making a subdermal infiltration beneath the 
area from which they are to be raised. Case No. 11808, shows 
the application of the above method in treating chronic osteo- 
mvelitis. 

Report of Case No. 11808. 

Mrs. II. S. 1)., aged twenty-nine years, entered hospital on 
November 19, 1918. 

Diagnosis: Chronic osteomyelitis (bone abscess) of the right 
tibia. 

Operation: Channeling excision of necrotic tissue and intro¬ 
duction of Beck skin flaps. 

Anesthesia: Circumferential infiltration block, 90 cc of 1 per 
cent novocain-adrenalin solution. 


SURGERY OF THE SHOULDER AND CLAVICLE 


291 


History: Patient had a discharging sinus over the upper end of 
the right tibia when she was seven years old. No further trouble 
was noted until she was in an accident six weeks before entering 
hospital. Now has continuous pain at the upper end of the tibia. 
The roentgenogram shows a shadow from 2 to 3 cm. long and 2 
cm. wide at the upper end of the right tibia. 

Technic of Anesthesia: 90 cc of novocain-adrenalin solution was 
introduced circumferentially—the needle passing laterally and 
posteriorly to the tibia just below the knee-joint. A small dis¬ 
charging sinus was excised, the periosteum elevated and a channel 
cut by means of the mallet and gouge, removing approximately 
one-third of the circumference of the tibia. A number of chisel 
points were broken because of the eburnation of the bone. The 
endosteum was found to be sensitive but thorough curettage was 
made. Pedicle flaps were turned in on each side and good results 
followed. 


CHOICE OF METHODS OF PRODUCING LOCAL ANESTHESIA 

IN THE UPPER EXTREMITIES. 

Dislocation of the shoulder may be reduced after making the 
brachial plexus block of Kulenkampff, and if for any reason one 
is unable to locate the brachial plexus a direct infiltration into 
the joint with a circumferential block proximal to the joint 
will give sufficient anesthesia and relaxation so that reduction 
may be accomplished. Dislocation of the elbow-joint may be 
reduced under brachial anesthesia or the venous anesthesia of 
Bier (Chapter V). Dislocation of the carpal bones and phalanges 
may be reduced after a transverse block at or above the wrist 
joint or by the establishment of brachial anesthesia. The three 
nerves supplying the hand are easily located at this level (Fig. 99, 
page 274, also Plate VI), and a perineural infiltration may be made 
in the region of each, following wdiich anesthesia will be complete 
in about fifteen minutes. 

SURGERY OF THE SHOULDER AND CLAVICLE. 

Nerve Supply of the Shoulder and Clavicle Region.— The skin 
over the region of the shoulder is supplied by nn. supraelaviculares 
posteriores (III, IV C) to the upper and posterior part of the 
shoulder; the anterior and lateral brachial cutaneous nerves of n. 
axillaris (V, VI C) to the region of the deltoid; n. intercostobrachialis 
(II T) to the axillary region and proximal arm. 

The muscles and fascia are supplied by muscular branches of 
these nerves. 


292 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


The shoulder joint is supplied by articular branches of n. supra- 
scapularis (V. VI. C). 

The skin over the region of the clavicle is supplied by nn. supra- 
claviculares anteriores and nn. supraclaviculares medii (II. IV. C.) 
(see Fig. 36, A, B, and C, page 171). 

Technic of Anesthesia.— Fracture, dislocation or other affections 
of the clavicle may be operated upon under direct infiltration com¬ 
bined with a deep injection along the upper border of this bone. 
Care must be taken to avoid the large vessels which lie directly 
beneath the bone. If the injection is made with the needle point 
impinging upon the bone there is no danger of injecting a vessel. 
After exposing the clavicle, anesthesia may be reinforced when¬ 
ever it is found to be necessary. One may, however, with a little 
care, completely anesthetize this region before any operative 
procedure is begun. 

This technic has been employed frequently even for the reduction 
of fractures of the clavicle by the closed method. The application 
of the first dressings may in this manner be converted into a pain¬ 
less procedure. 

Brachial Anesthesia.— For all operative work upon the upper 
extremity, including the reduction of fractures and dislocations, 
the brachial anesthesia of Kulenkampff offers many advantages. 
When established it gives excellent anesthesia. Its accomplish¬ 
ment is not difficult and, provided the injection is made slowly 
and certain precautions observed, it is comparatively safe (Fig. 
30, page 130). 

In order to produce this anesthesia it is essential that one has 
the cooperation of the patient, for in no other manner can one be 
cognizant of the fact that the needle point has been introduced 
into the nerve bundles. Also, the injection is most easily made 
with the patient in a sitting posture. Where for any reason it is 
impossible for a patient to assume a sitting position additional 
difficulties are encountered in locating the nerve, as the direction 
of the needle along the lines of certain anatomical landmarks is 
interfered with. 

The close proximity of the subclavian vessels to the bundles of 
the brachial plexus makes necessary special precautions if one is 
to avoid the introduction of the solution directly into the circu¬ 
lation. As the needle point must be stationary when the solution 
is injected it is well to use a fairly large needle and to delay and 
aspirate one or more times while the solution is being introduced. 
The introduction of the solution should be made slowly so that 
the nerve tissues will not be torn or traumatized. From time to 
time there have appeared in the literature reports of the loss of func¬ 
tion which was supposed to have resulted from injury to the brachial 


SURGERY OF THE SHOULDER AND CLAVICLE 


293 


plexus after the induction of this form of anesthesia. The author’s 
experience with several hundred cases with no untoward after¬ 
effects makes him feel like offering the suggestion that such effects 
are unlikely to follow if the solution is injected sufficiently slowly 
to avoid traumatization. Cases Nos. 10014, 11555 and 12187 
are examples of shoulder subluxation, dislocation and fracture 
of the humerus respectively, which were treated surgically by the 
use of brachial block. 

The following case will illustrate the application of brachial 
anesthesia to simple subluxation of the shoulder joints: 


Report of Case No. 10014. 

K. J. M., aged fifty years, entered the hospital on August 18, 
1917. 

Diagnosis: Subluxation of the left shoulder-joint. 

Operation: Reduction by closed method. 

Anesthesia: Brachial block (Fig. 30, page 130), using 5 cc of a 
1 per cent solution. There was numbness of the hand seven minutes 
after the injection of the brachial plexus. Complete relaxation 
was obtained and reduction was accomplished by manipulation. 

In this case, induction of anesthesia and reduction of the dis¬ 
location required but ten minutes. 


Report of Case No. 11555. 

Mrs. N. B. C., aged thirty-five years, entered hospital June 3, 
1918. 

Diagnosis: Fracture-dislocation of head of right humerus. 

Operation: Reduction by manipulation. 

Anesthesia: Brachial block. The plexus was located instantly 
and 5 cc of a 1 per cent novocain-adrenalin solution were used. 
Anesthesia was complete in five minutes. Reduction was made 
with the aid of the fluoroscope. Strohmeyer pad placed in axilla 
and dressings applied. 


Report of Case No. 12187. 

B. M. D., aged twenty-four years, entered hospital August 8, 

1919. 

Diagnosis: Oblique fracture of the humerus. 

Operation: Reduction by closed method. 

Anesthesia: Brachial block. 


294 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


History: Patient entered hospital with a fracture which had 
been sustained two hours before his examination. The left humerus 
showed a spiral fracture with considerable shortening. 

Anesthesia: Brachial anesthesia (Fig. 30, page 130), using 10 
cc of a 1 per cent novocain-adrenalin solution. 

Operation: Reduction was made directly under the fluoroscope 
and a modified Thomas splint applied. The patient was allowed 
to leave the hospital thirty minutes after entering. 

SURGERY OF THE ELBOW-JOINT. 

The nerve supply of the region of the elbow-joint is as follows: 
(See Plates V, VII and VIII.) 

The skin overlying this region is supplied by (1) n. intercosto- 
brachialis (II. T) to the medial side of the arm and not beyond 
the elbow-joint; (2) n. cutaneus brachii posterior from n. radialis, 
V. VI. VII. VIII. C. I. T., also to the medial side; (3) n. cutaneus 
antibrachii dorsalis, also from the radial to the lateral and posterior 
distal third of the arm and the dorsal part of the proximal half 
of forearm; (4) n. cutaneus antibrachii lateralis of n. museulo- 
eutaneus, V. VI. C. to the lateral side of the forearm; (5) n. cuta¬ 
neus antibrachii medialis, VIII. C. I. T., to the medial side of 
the forearm. 

The elbow-joint proper is supplied by articular branches of n. 
medianus V. VI. VII. VIII. C. I. T. and n. ulnaris VIII. C. I. T. 

The muscles and fascia of this region are supplied by branches 
of the ulnar, median, radial and musculocutaneus nerves, and it 
will be noted that the nerve supply of this region is primarily from 
the fifth cervical to the first thoracic nerves. 

Arthroplasty.— The choice of the methods of producing local 
anesthesia of the elbow-joint lies between the brachial anesthesia 
of Kulenkampff (Fig. 30, page 130) and the venous anesthesia of 
Bier (Chapter V). The margin of error is perhaps greater in the 
case of brachial anesthesia. The other method allows one an 
excellent opportunity for carrying out the technical details of the 
operation. In case a fat-fascia-transplant is to be used the technic 
described on page. 164 may be used in isolating from its nerve 
supply the area from which the transplant is to be obtained. 

The following case will illustrate the use of brachial and infil¬ 
tration anesthesia in the performance of this operation. 

Report of Case No. 14221. 

M. I. K., aged twenty-six years, entered the hospital April 13, 
1921. 

Diagnosis: Ankylosis of the elbow-joint, following suppurative 
arthritis. 


SURGERY OF THE ELBOW-JOINT 


295 


Operation: Arthoplasty of the elbow-joint. 

1 echnic oj Anesthesia: Brachial block and local infiltration 
(saligenin). 

Anesthesia: Brachial anesthesia (Fig. 30, page 130), using 10 cc 
of saligenin, 4 per cent. The patient was extremely nervous and 
presented a typical picture of psychic incompatibility, being 
hypersensitive and suspicious. Her lack of cooperation during 
the establishment of the brachial anesthesia left us in doubt as to 
whether the plexus had been located. The anesthesia about the 
elbow-joint was incomplete and a local infiltration was employed 
to reinforce it. 180 cc of a 2 per cent solution of saligenin were 
used. 



Fig. 114.—Arthroplasty of elbow-joint. Photograph of Case No. 14221, after 

operation. (Brachial anesthesia.) 


Operation: The bones were exposed and the classical Murphy 
operation performed, with the exception that the transplant of 
fascia and fat was taken from the thigh of the same side, as the 
tissues of this nature about her elbow were extremely scant. Pri¬ 
mary healing resulted. Fig. 114 is a composite photograph of 
this patient showing the range of motion after operation. 

Venous anesthesia furnishes also an excellent method for making 
elbow operations, as it permits of no margin of error. 

Report of Case No. 15494. 

O. S. G., female, aged eighteen years, entered hospital March 
6, 1922. 






296 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


Diagnosis: Unreduced dislocation of right elbow. 

Operation: Open method of reduction. 

Anesthesia: Venous anesthesia of Bier. 

History: The patient had chronic glomerular nephritis; blood 
urea-N., 99 mgm. per 100 cc; blood creatinine, 4.9 mgm. per 100 
cc; blood Van Slyke, 54 per cent; P. S. P. excretion, 0 during two- 
hour period. 90 cc of a 1 per cent novocain-adrenalin solution 
were injected into the median basilic vein as described on 
page 112. 

The anesthesia was complete and immediate. The elbow-joint 
was remodelled, two incisions being made. A large amount of 
callus was removed from the semilunar notch of the ulna. The 



Fig. 115.— Arthroplasty of elbow joint. Photograph of Case No. 15494, during 

operation. (Venous anesthesia.) (Bier.) 


^ oun d healed hiridl\ j hut one week after operation the patient 
showed marked symptoms of uremia and for several days her life 
was despaired of. She finally recovered, although, of course, her 
lease on life is rather short. 

Note .—This girl underwent this severe operation without an 
immediate reaction and the reaction she did show did not appear 
until one week after the operation. From experience with cases 
of this kind one is led to feel that general anesthesia over a long 
period of time as is necessitated by such a condition is absolutely 
contraindicated. Venous or brachial anesthesia are entirely satis¬ 
factory. 

%j 

Fig. 115 shows the patient during the operation. 




297 


SURGERY OF THE HIP 

SURGERY OF THE WRIST. 

Nerve Supply of the Wrist. —(Plates VI, VII and VIII.) The 

skin over the region of the wrist is supplied by (1) n. cutaneus 
antibrachii cutaneus lateralis of n. musculocutaneus (V. VI. VII. 
( ) to the lateral and dorsal side; (2) n. cutaneus antibrachii medialis 
0 III. C. I. T.) to the ulnar side of the wrist; (3) n. cutaneus anti¬ 
brachii dorsalis of n. radialis (\ . X I. Y II. \ III. I. T.) to the posterior 
ridge; and (4) a cutaneous branch of n. ulnaris (VIII. C. I. T.). 

The joint and fascia are supplied by branches of the ulnar, 
radial and median nerves. 

All operations upon the hand may be performed after establish¬ 
ing conduction anesthesia brachial block or by an infiltration block 
at the wrist joint as shown in Case No. 12277. 

Report of Case No. 12277. 

Id. J. C., aged sixty-three years, entered hospital September 10, 
1919. 

Diagnosis: Dupuytren’s contraction of left hand. 

Operation: Excision of palmar fascia—Keen’s incision. 

Technic of Anesthesia: Infiltration block at the wrist catching 
the ulnar and median nerves. Anesthesia was immediate and 
complete. The classical operation was performed. 

SURGERY OF THE HIP. 

Nerve Supply of the Lower Extremity in the Region of the Hip- 
joint. —The skin overlying the region of the hip-joint is supplied 
by: (1) n. cutaneus femoris lateralis (II. III. L.), which supplies the 
anterior and lateral sides; (2) n. lumboinguinalis, which is a branch 
of n. genitofemoralis (I. II. L.) and supplies the anterior surface; 
(3) n. ilioinguinalis (I. L.) to the medial thigh; (4) ramus cutaneus 
lateralis of n. iliohypogastricus (I. L.) to the gluteal region; (5) 
ramus cutaneus lateralis of the twelfth thoracic to the front part 
of the gluteal region; (6) the lateral cutaneous branches of the 
posterior divisions (I. II. III. L.) to the buttocks; and (7) the 
lateral branches of the posterior divisions of I. II. III. S. to the 
posterior part of the buttocks. 

The hip-joint is supplied by (1) an articular branch of the anterior 
part of n. obturatorius (II. III. IV. L.), which enters through the 
acetabular notch; (2) by another articular branch of the femoral 
nerve (n. femoralis) (II. III. IV. L.); and (3) by articular branches 
from the nerve to the quadratus femoris (IV. V. L. I. S.) and from 
the tibial part of the sciatic nerve (n. ischiadicus) (IV. Ah L. I. 
II. III. S.). 


298 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 

The muscles and fascia are supplied by branches from these 
various nerves. 

Therefore, the nerves from the first lumbar to the third sacral 
are involved. 

It will be seen that the sensory nerve supply to this joint and 
to the tissues which one must traverse when attacking it surgically 
is somewhat complicated and that its interruption by conduction 
anesthesia is by no means a simple procedure. We have depended 
upon direct infiltration of the tissues for the production of anes¬ 
thesia of the hip-joint, varying the technic to meet the indications. 

Open Operations.— Open operations upon the hip-joint may be 
carried out as follows: 

Technic of Anesthesia: x4 subdermal infiltration along the line 
of the proposed incision is made, followed by a subfascial infil¬ 
tration down to the femur. In making the deep infiltration a 
wall of anesthesia may be built both behind and in front of the 
femoral neck. If possible the patient should be placed upon the 
unaffected side. The landmarks should be carefully noted. There 
is practically no structure upon the posterior surface that will 
interfere with infiltration. A long, fine needle may be carried 
directly to the bony surface of the ilium and the injection made 
with the point of the needle constantly moving. In front it is 
necessary only to avoid contact with the large vessels which lie 
well medial to the path of the needle. From 90 to 180 cc of solution 
may be required, depending upon the size of the patient. Every 
effort must be made to secure physical comfort for the patient’s 
body during the carrying out of the operation. Movements of 
the affected limb must be made cautiously at first, and always with 
the anticipation of pain, until one is assured, after careful experi¬ 
mentation, that anesthesia is complete. While at rest the limb 
should be rigidly supported and the utmost care observed in pre¬ 
venting sudden motion in it, that for instance which might result 
from the dropping of the limb by a careless assistant. As the 
incision advances the anesthesia may be reinforced providing the 
blocking has not been complete. As soon as the femoral neck 
and head can be definitely located any further manipulations 
should be preceded by the introduction of about 30 cc of the solution 
in close proximity to as well as into the joint. At this stage it is 
possible to reach the nerve branches which course through the 
acetabular foramen, and which are not so easily accessible at the 
beginning of the operation. Perfect exposure of the tissue planes 
must be insisted upon here as in all other operative procedures 
if local anesthesia is to be successfully employed. By following 
these simple rules and working deliberately and without haste 
the hip-joint may be painlessly exposed for any operation which 


SURGERY OF THE HIP 


299 


may be required in this region. The acetabulum or iliac bone may 
be chiselled, curetted or drilled into without pain to the patient, 
provided the region has been properly anesthetized. Case No. 
11298 exemplifies an open operation with bone pegging for ununited 
fracture of the femur by the use of local infiltration. 


Report of Case No. 11298. 

A . F., aged fifty-three years, entered hospital on January 25, 
1918. 

Diagnosis: Ununited fracture of neck of left femur. 

Operation: Open operation and bone pegging. 

Anesthesia: Local infiltration, 120 cc of a 0.5 per cent novocain- 
adrenalin solution. 

History: Seven months before entering the hospital, patient 
fractured the neck of the left femur while at work in a mill. 

Operation: Direct infiltration was made along the line of incision 
proposed by Dr. A. J. Gillette, about 120 cc of a 0.5 per cent 
solution being used. The hip-joint was exposed, the fractured sur¬ 
faces freshened and two beef-bone pegs were inserted through 
drill holes. The incision was closed and a plaster spica applied. 
The patient went through this operation entirely without pain 
and cooperated with us while the plaster cast was being applied. 
Staphylococcus infection followed the operation but did not greatly 
delay convalescence. 

Fractures and Dislocations.—Technic of Anesthesia.— The reduc¬ 
tion of fractures and dislocations has been accomplished with 
considerable less difficulty than was anticipated, although experience 
with this class of work has been comparatively small. The technic 
as described for the open operation is carried out with the exception 
of the making of the subdermal infiltration. In place of this a 
number of secondary wheals are made upon the skin, advancing 
the needle through the initial wheal, which is usually made directly 
over the greater trochanter. From this point a wheal is made at 
a point on the skin directly in front of the acetabulum and external 
to the location of the femoral vessels. One or two wheals are 
made below the greater trochanter and one or two on the posterior 
surface of the buttock at points which will permit one to infiltrate 
thoroughly the tissues about the acetabulum, the greater trochanter 
and the femoral neck. As soon as the infiltration has been accom¬ 
plished it will be found possible to abduct the limb sufficiently 
so that a skin wheal may be made on the inner side of the thigh, 
if this is thought desirable, close to the perineum, through which 
the acetabulum may be reached and the circuminjection of the joint 
completed. The following case report is inserted to illustrate the 
application of the method: 


300 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


Report of Case No. 13400. 

M. F. H., aged twenty-one years, entered hospital September 
25, 1921. 

History: While playing football, patient was tackled and thrown, 
striking on his left hip. He was unable to use the limb and has 
had considerable pain since the injury. 

Complaint: Injury to left hip. 

General Examination: Negative. 

Examination of Left Lower Limb: Left foot was rotated inward, 
lying across the instep of the right foot, with the left knee lying 
against the right. Limb partially flexed. Muscles extremely 
tense. Greater trochanter above Nelaton’s line. 



Fig. 116.—Dislocation of the hip. Roentgenogram of Case No. 13400, showing 

dislocation. 


Diagnosis: Dislocation of left hip. 

Operation: Reduction by closed method. 

Technic of Anesthesia: Local infiltration. 

Operation: No preliminary hypodermics. An infiltration block 
was made, using 90 cc of a 1 per cent novocain-adrenalin solution, 
following the direction of the femoral neck with a 12 cm. needle. 
Before 90 cc were injected the large muscles were completely relaxed. 
Slight movement of the femur was painless and the limb was per- 



SURGERY OF THE IIIP 


301 



Fig. 117.—Dislocation of the hip. Roentgenogram of Case No. 13400, after 

reduction. 



Fig. 118.—Dislocation of the hip. Photograph of Case No. 13400, directly after 

reduction. 




302 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


fectly comfortable, whereas he had been suffering considerable 
pain before the injection was made. 90 cc more were used, with 
the result that the boy could be lifted from the stretcher and laid 
on the floor without producing pain. Five minutes after the 
injection was finished the dislocation was reduced by manipulation. 
Two assistants held the pelvis in contact with the floor while the 
surgeon made the manipulations, assistance being necessary in 
order to lift the head over the rim of the acetabulum. The fifth 
attempt was successful. Roentgenograms show the condition before 
(Fig. 116) and after (Fig. 117), and the photograph (Fig. 118) 
was taken directly after the reduction. 

Arthroplasty of the Hip.— The anesthesia required for carrying 
out the procedure known as arthroplasty of the hip-joint differs 
in no manner from that described for anesthetizing the region of 
the hip-joint for the treatment of other conditions, such as the 
open operation for fracture. 

The following case will serve as an illustration: 

Report of Case No. 10603. 

C. T. R., aged fourteen years, entered hospital February 3, 1917. 

Diagnosis: Ankylosed right hip with acute flexion. 

Operation: Arthroplasty, Murphy operation. 

Technic of Anesthesia: Local infiltration and nitrous oxide and 
oxygen. (Mixed anesthesia.) 

History: Two years ago the patient developed suppurative 
arthritis of right hip, which is completely ankylosed in rather 
marked flexion. 

Operation: February 6, 1917. A circumferential block of the 
hip-joint was carried out, using 180 cc of a 0.5 per cent novocain- 
adrenalin solution. The classical Murphy operation was performed, 
using a pedicle flap of fat and fascia. 

This patient was given nitrous oxide and oxygen during the 
manipulation of the hip, which was necessary for mobilization 
purposes. The presence of the scar tissue was considered a con¬ 
traindication to local infiltration and spinal or general anesthesia 
might be more satisfactory in such a case. Furthermore, this 
patient’s wound suppurated profusely, and although it is our experi¬ 
ence that local infiltration does not reduce the resistance of the 
tissues, this case proved to be rather unsatisfactory in its outcome. 

FRACTURE OF THE FEMUR. 

Closed Operation. —Technic of Anesthesia.— The reduction of 
simple fractures of the femur by the use of local anesthesia may 


FRACTURE OF THE FEMUR 


303 

be made following a transverse block at a point 10 to 15 cm. above 
the line of fracture or, if high up, the technic may be made to 
correspond closely to that used for operations upon the femoral 
neck. This technic will suffice for fractures of the upper third. 
Fractures below this may be reduced after the transverse block 
has been made, with the addition of a liberal injection about the 
seat of fracture. 

Open Operation.—We have in a number of instances reduced 
both recent and old fractures of the femoral shaft by the open 
method. Perfect local anesthesia gives good relaxation of the 
muscles and as these operations are always a tax upon the patient’s 
strength we feel that local anesthesia is especially indicated in this 
field. 

Technic of Anesthesia.—A subdermal infiltration should be made 
along the line of incision followed by a transverse block at the 
level of the upper end of the incision combined with a circum- 
injection of the femur. The injecting needle should be carried alter¬ 
nately in front of and behind the bone. (Figs. 101, 102 and 103, 
page 275.) The solution must be used liberally and in stout indi¬ 
viduals we have employed as high as 300 cc. It may be well in 
these cases to apply a tourniquet just above the field of operation 
in order to reduce the possibility of toxicity. However, in a fairly 
large experience the author has seen no ill effects from the use of 
from 200 to 300 cc of 0.5 to 0.7 of a 1 per cent novocain-adrenalin 
solution. Perfect relaxation is obtained and the tendency to 
bleeding is greatly reduced. Liberal incisions and good exposure 
are desirable. Provided a transplant is to be made a subdermal 
infiltration may be made along the line of the proposed incision 
through which it is to be removed. Through this a rectangle may 
be marked out upon the tibia by carrying the needle point directly 
to the periosteum along two lines, one external to and the other 
medial to the outlines of the transplant. By the time one is ready 
to remove the transplant anesthesia will be found complete in this 
region. 

As an example of a handicapped individual presenting a severe 
injury demanding an open operation the following case may be 
cited: 

Report of Case No. 11862. 

Mrs. S. E. B., aged seventy-one years, entered hospital December 
18, 1918. 

Diagnosis: Supracondvloid T-fracture of the right femur. 
(Fig. 119.) 

Operation: Incision, reduction and application of screws. 

Anesthesia: Transverse infiltration block. 


304 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


History: Thirteen days before admission to the hospital the 
patient had sustained a severe injury to the right knee by falling 
down stairs. No subsequent efforts at reduction had been made. 
Roentgenographic plates showed a transverse fracture of the femur 
beginning 8 cm. above the knee-joint, dividing the condyles and 
extending into the knee-joint. There was practically 8 cm. shorten¬ 
ing, the lower distal fragment being displaced backward. The 
patient was short and stout. The urine contained a moderate 
amount of albumin, hyaline and granular casts. 

Technic of Anesthesia: Infiltration block, novocain-adrenalin, 
180 cc. 



Fig. 119. —Fracture of the femur, lower end. Roentgenogram of Case No. 11862, 

before operation. 


The patient was given no preliminary hypodermic medication. 
She was placed upon the extension apparatus, great care being 
taken to make her as comfortable as possible. She Was held in 
position by applying the extension screws, and the skin was pre¬ 
pared by painting with iodin. The line of incision—25 cm. in 
length—was infiltrated, each excursion of the needle bringing its 
point in contact with the femur. An especially large deposit 
of solution was made just posterior to the bone in the region of 
the fracture. The bone was exposed and the fragments gently 
separated by the use of a scalpel and chisel. In the meantime the 
traction screws were brought into play, and the lower fragments 
were gradually brought down to the proper level. One long screw 



THE KNEE-JOINT 


305 

and a stove bolt were introduced, after drilling the bones in order 
to prevent a recurrence of the displacement (for radiogram before 
operation see Fig. 119) after operation, the fractured surface being 
rather oblique. This patient left the table with a pulse of 80; there 
was no hemorrhage, no shock, no pain, and she presented no post¬ 
operative complications. Fig. 120 shows the reposition of the 
fragment. 



Fig. 120. —Fracture of the femur, lower end. Roentgenogram of Case No. 11862, 

after operation. 


THE KNEE-JOINT. 

(Fig. 100, page 274, and Plates XII and XIII.) 

The Nerve Supply. —The knee-joint is supplied by an articular 
branch of the common peroneal nerve, n. peroneus communis 
(IV. Ah L. III. S., and sacral plexus) by (2) three articular branches 
of n. femoralis (II. III. IV. L.) by (3) an articular terminal branch 
of n. obturatorius (II. III. IV. L.) by (4) an articular branch of n. 
ischiadicus (IV. S. L. I. II. III. S.) and by (5) articular branches of 
n. tibialis (IV. V. L. I. II. III. S.). Thus it is seen that the joint is 
supplied by nerves from fourth lumbar to third sacral. 

The skin overlying the knee-joint is supplied by cutaneous 
branches (intermediate, medial and saphenous) of n. femoralis 
(II. III. IV. L.) which supply the sides and front of knee, and 
n. cutaneus femoris posterior (I. II. III. S.) which completes the 
supply over the popliteal space. 

The muscles and fascia are supplied by muscular branches of 
practically the same nerves mentioned above, Thus the supply 
20 




306 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


of the skin over the knee-joint is from second lumbar to third 
sacral. 

Technic of Anesthesia.— The technic of producing anesthesia in 
and about the knee-joint will depend somewhat upon the nature 
of the operative procedure which is to be carried out. 

Resection, the reduction of complicated fractures and arthro¬ 
plasty demand a transverse block well above the joint, combined 
with a subdermal infiltration along the lines of incision. (Fig. 121.) 



Fig. 121 Fig. 122 

Fig. 121.—Anesthesia of the knee. Transverse subdermal infiltration. Disten¬ 
tion of joint with anesthetic solution. (See next Fig. 122.) 

Fig. 122.—Anesthesia of the knee. Distention of joint with anesthetic solution. 
Sectional view of Fig. 121. 1, tendon of rectus femoris muscle; 2, bursa supra- 

patellaris; 3, femur; 4, ligamentum collateral fibulare; 5, tendon of popliteus muscle. 
6, bursa M. popliteus; 7, fibula; 8, tibia; 9, cavum articulare; 10, patella; 11, 
ligamentum patella; 12, bursa infrapatellaris profunda. 


In most of the work upon the knee-joint it is desirable to make 
a subdermal infiltration along the proposed line of incision and 
to follow this by the instillation into the joint of 30 to 60 cc of the 
anesthetic solution. By the time the incision reaches the joint 
capsule, which is also a sensitive structure and requires infiltration 
the solution will have acted upon the sensitive joint membranes 
and fairly good anesthesia will result. (Fig. 122.) 






















THE KNEE-JOINT 


307 


Fracture of the Patella.—Technic of Anesthesia.— In suturing a 
fractured patella simple infiltration carried well past the lateral 
limits of the patella will produce excellent anesthesia. It is neces¬ 
sary only to carry the line of infiltration above the line of fracture 
and the needle should strike the femur at every stroke. (Fig. 121.) 

In these cases the knee-joint should be distended with novocain- 
adrenalin solution before the operation begins (Fig. 122), as anes¬ 
thesia of the joint surfaces is desirable in case clots are to be removed. 

Case No. 1403 is the author’s first case of fracture of patella 
operated upon under local anesthesia. 


Report of Case No. 


1403 


>. 


R. I). A., aged eighteen years, entered hospital January 11, 1908. 

Diagnosis: Transverse fracture patella—left. 

Operation: Incision, suture with catgut. 

Technic of Anesthesia: Local infiltration 0.5 per cent novocain- 
adrenalin solution. 

A direct infiltration by a series of intradermal wheals. The 
skin was anesthetized and incised. The incision was made through 
the skin and fat and the tissues infiltrated at the patient’s demand. 
The anesthesia was reinforced repeatedly, using syringes, and with 
some distress to the patient. The aponeurotic tissues were united 
with chromic catgut and the patient made an uneventful recovery. 

Note. —This case was one of my early ones and in its treatment 
the technic of that epoch was employed. It is interesting to com¬ 
pare this technic with that described on page 308, Case No. 7623. 

Floating Cartilages.—The removal of loose bodies and loose 
cartilages allows a more simple technic, as follows: 

The line of incision is anesthetized in the usual manner and 
through the anesthetized skin a needle is introduced until it reaches 
the capsule of the joint. After carefully anesthetizing the capsule 
the needle point is carried through the capsule into the joint which 
is then thoroughly distended with the solution (Fig. 122). The 
incision may now be made, and if one does not proceed too rapidly 
the joint surface will be found to be anesthetized when the joint 
is finally opened. 

In the removal of loose cartilages it has been found that the 
posterior attachments remain sensitive and it is well after making 
the first incision to reinforce the anesthesia at this point before 
severing the cartilage. Provided both sides of the knee are to be 
attacked one may pass a blunt-pointed forceps transversely across 
the joint. This marks the area over which anesthesia is to be 
established on the opposite side. The incision may then be carried 
down to the point of the forceps where it presents. 


308 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


Case No. 7623 shows the surgical management of loose cartilage 
of the knee-joint by an open operation under local and intra-capsular 
infiltration. 

Report of Case No. 7623. 

H. E. T., aged twenty-four years, entered hospital December 
15, 1914. 

Diagnosis: Loose cartilage in knee-joint. 

Operation: Excision of loose cartilage. 

Anesthesia: Local subdermal and intracapsular infiltration. 

History: Upon awakening one morning three years previous to 
his entry into the hospital he found his left leg locked with the knee 
in semi-flexion, although he had been perfectly well when he retired 
the night before. Some swelling, and disability followed for two 
weeks. Since that time the limb has been weak and locks fre¬ 
quently. 

Technic of Anesthesia: Infiltration block, 0.5 cc of 1 per cent 
novocain-adrenalin solution. 

On December 16, 1914, patient was operated upon. He was 
given morphin gr. \ and scopolamin gr. T ^-- 0 -, one hour before opera¬ 
tion. A rhomboid subdermal infiltration of novocain 0.5 of 1 per 
cent was made over the internal aspect of the knee. A fine needle 
was introduced into the joint and 60 cc of the solution were allowed 
to flow into the joint. The Jones incision was made, the joint 
capsule opened and the loose cartilage removed. 10 cc of | of 
1 per cent quinine and urea hydrochloride solution were deposited 
in the joint at the close of the operation. Later, the patient, 
however, suffered severe pain and required several hypodermics 
during the following twenty-four hours. 

THE LEG. 

Fractures, Closed Operations.— In fractures of the leg, as in 
fractures elsewhere, it is well to make a transverse block well above 
the point of fracture and to allow considerable time to elapse before 
attempting reduction. Fractures about the ankle-joint as well 
as those of the foot may be reduced under a transverse block at a 
point from 5 to 10 cm. above this joint. The nerve trunks are 
well marked out by easily mastered landmarks, and not more than 
60 or 90 cc of solution are required. The use of a rubber tourni¬ 
quet is advantageous in these cases and allows one to make the 
injection freely. The removal of the tourniquet should be made 
gradually, as its sudden removal, if made early, may be the means 
of allowing a considerable amount of the solution to be taken up 
by the circulatory system in a short period of time, This cir* 


THE LEG 


309 


cittnstance may be followed by faintness, pallor and increased 
pulse rate in the patient. 

Case No. 11641 is an example of fracture of the leg reduced and 
immobilized painlessly by a transverse local infiltration block. 


Report of Case No. 11641. 

L. G. C., aged thirty-nine years, entered hospital August 4, 
1918. 

Diagnosis: Fracture of the leg at the lower third. (Both bones 
were broken and there was great displacement.) 

Operation: Reduction of fracture. 

Anesthesia: Transverse infiltration block of leg. 

Technic of Anesthesia: 90 cc of 0.5 of 1 per cent novocain-adren¬ 
alin solution were injected on a line 5 cm. above the site of the 
fracture (Fig. 100, page 274), and in ten minutes anesthesia was 
complete. 

The leg was angulated nearly to a right angle and the fractured 
ends, which were only slightly oblique, were brought in contact 
and the leg straightened, thus overcoming the shortening. Moulded 
plaster splints were applied. In this case relaxation was perfect, 
and there was no pain. 

The following case will illustrate the use of conduction anes¬ 
thesia in fractures of the leg: 

Report of Case No. 9400. 

B. J. J., aged forty-nine years, entered the hospital November 
7, 1916. 

Diagnosis: Fracture of both bones of right leg at the midpoint. 

Operation: Reduction of fracture, closed method. 

Anesthesia: Sciatic nerve block. 

History: Man fractured his leg in a fall a few hours previously. 

Technic of Anesthesia: The sciatic nerve was blocked at the 
gluteal fold, the needle point causing paresthesia along the course 
of the nerve. Fifteen cc of a 2 per cent novocain-adrenalin solution 
were slowly injected and anesthesia was complete in ten minutes. 

The fractured fragments which overlapped each other consider¬ 
ably were replaced by extension and manipulation. There was 
excellent relaxation and reduction was made without pain, after 
which a plaster-of-Paris cast was applied. 

Note.— In other cases, however, one may be less fortunate in 
reaching the sciatic, for even when this nerve trunk has apparently 
been injected, anesthesia has not always been complete. 


310 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


SURGERY OF THE ANKLE-JOINT. 

(See Plates XII, XIII and Fig. 38.) 

Nerve Supply.— The ankle-joint is supplied by (1) an articular 
branch of n. tibialis (IV. V. L. I. II. III. S.); (2) articular branches 
of n. plantaris medialis (of tibial) (IV. V. L. I. II. III. S.) to the 
tarsometatarsal articulation; and (3) an articular branch of n. 
peroneus profundus branch of the common peroneal (IV. V. L. I. 
II.S.). 

The skin overlying the ankle-joint is supplied by (1) the n. 
saphenous of n. femoralis (II. III. IV. L.) on the medial side; (2) 
the medial and intermedial dorsal cutaneous branches of n. per¬ 
oneus superfieialis, which in turn comes from n. peroneus communis 
(IV. V. L. I. II. S.) and supply the dorsal and lateral surfaces of 
the ankle; and (3) the n. suralis which is a branch of n. tibialis 
(IV. V. L. I. II. III. S.) and supplies the posterior surface. 

Thus the nerve supply of the ankle is seen to arise primarily 
from the fourth lumbar to the third sacral and by terminal branches 
of the femoral, common peroneal and tibial, corresponding to the 
ulnar, median and radial of the wrist. 

Special Fractures.—Pott’s Fracture. —Fractures in and about 
the ankle-joint are among the most simple to treat under local 
anesthesia. An infiltration block 5 to 10 cm. above the point of 
injury gives excellent anesthesia and relaxation. (Fig. 100, page 
274.) 

The following case report will serve to illustrate the application 
of local anesthesia in injury to the ankle-joint. 

Report of Case No. 7188. 

J. T. M., aged seventy-eight years, entered hospital January 
20, 1916. 

Diagnosis: Pott’s fracture—left. 

Operation: Reduction by closed method. 

Anesthesia: Transverse infiltration block, 90 cc of 0.5 per cent 
novocain-adrenalin solution used. 

A transverse infiltration block was made 6 cm. above the ankle- 
joint. Perfect relaxation resulted and the limb was dressed with 
plaster in the inverted position. 

Note .—This patient was extremely feeble, her home was in 
another city, she was visiting her sister who lived in my vicinity 
and she had just partaken of a heavy dinner. The above pro¬ 
cedure was carried out with almost no inconvenience and the 
patient continued her visit without interruption. 


HALLUX VALGUS 


311 


The Cadivilla Pin. — Technic of Anesthesia .—The introduction 
of the Cadivilla pin is preceded by the development of an initial 
wheal in the skin at the point where the pin is to be inserted. 
Through this wheal the needle is introduced in a direction vertical 
to the skin surface and the tissues between the skin and the bone 
thoroughly infiltrated. (In case the broken fragments are to be 
manipulated the transverse block, page 274, Fig. 100, should be 
established.) This technic is then repeated upon the opposite 
side. The skin is then incised and a drill forced through the bone. 
This procedure may be as easily carried out in the home as in a 
hospital. 

In introducing a traction pin through the os calcis (Anscheutz) 
the same technic is employed. The drilling of the bone is not 
painful, provided the periosteum is anesthetized. Anesthesia should 
be established on both sides before drilling the bone. 



infiltration; E, infiltration block. 


HALLUX VALGUS (BUNIONS). 

Technic of Anesthesia.— The operation for bunions or for any 
operation, in fact, upon this portion of the foot may, provided the 










312 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


proper technic is followed, be done under local anesthesia with 
the greatest satisfaction. The anesthesia should be absolute. 
Its establishment should be painless except for the production of 
the primary skin wheal and there is no margin of error. The rules 
laid down on page 149 (Fig. 31), in relation to intradermal and sub- 
dermal wheals and on page 271, regarding the manner of anesthe¬ 
tizing the plantar surfaces of the hands and feet should be rigidly 
observed. Approximately 60 cc of a 1 per cent solution of novo¬ 
cain-adrenalin are required for each foot and the operation may 
be begun as soon as the injection is finished. It has been the 
author’s practice to anesthetize both feet, beginning the operation 
upon the foot which was first anesthetized as soon as the anesthetic 
had been injected into the second foot. Figs. 123 and 124 show 
the technic of making the infiltration. 



Fig. 124.—Anesthesia technic for bunion operation. A, B, C, D and-E, infil¬ 
tration block. 

VARICOSE VEINS OF THE LEG. 

The sensory nerve supply (see Fig. 125) of the lower limb lends 
itself especially well to the production of local anesthesia for the 
excision of varicose veins. Fig. 126 shows a satisfactory technic 
for this work. A transverse infiltration is made at the upper¬ 
most point at which the vein is to be attacked and this injection 
should be carried down to the muscular aponeurosis. Two rows 
of subdennal infiltration are carried along the course of the veins 
to a point just above the knee and here another transverse line 
is made. From this point one may carry the needle subdermally 
and make the initial wheals from beneath and establish as many 
transverse lines of infiltration as may seem necessary for the per¬ 
formance of the subsequent operation. After the establishment 












VARICOSE VEINS OF THE LEG 


313 


ot Anesthesia above, such a high percentage of the nerve filaments 
vill be anesthetized that infiltration below need be only moderate 
in amount. 




Fig. 125.—Anesthesia technic for varicose veins of the leg. Subdermal infiltra¬ 
tion and infiltration block. 

Fig. 126.—Sensory nerve supply of tissues involved in anesthesia for varicose 
veins of the leg. 1, N. lumboinguinalis; 2, V. saphena magna; 3, rami cutanei 
anteriores N. femoralis; 4, rami cutanei N. obturatoris; 5, rami cutanei anteriores 
N. femoralis; 6, V. saphena magna; 7. N. saphenus (branch of N. femoralis); 8, ramus 
infrapatellaris of N. saphenus; 9, rami cutanei cruris medialis of N. saphenus. 


























314 LOCAL ANESTHESIA IN SURGERY OF EXTREMITIES 


The time required is practically negligible as the injection may 
be made very rapidly. The author has in numerous instances 
performed the complete operation on both legs in less than forty 
minutes, including the establishment of anesthesia. 

The amount of solution required will depend largely upon the 
size of the individual. Extremely fat patients require much more 
than thinner ones. However, it is seldom necessary to use more 
than 180 cc of a 1 per cent solution, which is of course a perfectly 
safe procedure. Case 13903, which follows, shows the practical 
application of the above method. 



Fig. 127.—Anesthesia technic for varicose veins of the leg. Photograph of Case 
No. 13903 during operation. C, points to multiple incisions. 


Report of Case No. 13903. 

Id. J., aged sixty-nine years, entered hospital July 19, 1920. 

Diagnosis: Varicose veins of both legs. Osteomyelitis of the 
right great toe. (Chronic.) 

Operation: Trendelenburg ligation and excision; amputation 
of toe. 

Anesthesia: Local infiltration using 120 cc of a 1 per cent novo¬ 
cain-adrenalin solution. The operation was done without pre¬ 
liminary medication and the veins were ligated and excised under 
the technic illustrated by Fig. 126. The toe was amputated under 
infiltration block (Fig. 124). The patient whose picture is shown 
in Fig. 127, ate his luncheon at the completion of the operation 
and showed not the slightest reaction. 






CHAPTER XI. 


LOCAL ANESTHESIA IN SURGERY OF THE 
GENITO URINARY SYSTEM. 


ANESTHESIA AND GENITO-URINARY SURGERY. 

I nquestionably there is a close relation between renal function 
and the ability of patients to withstand surgical procedures. It is 
also true that patients demanding operations upon the kidney or, 
in fact, upon any part of the urinary tract are apt to suffer from 
more or less interference with renal function. It is important to 
meet the demands of this class of patients with every possible 
safeguard. 

r l he deleterious effects of ether and chloroform upon the economy 
of a patient with defective kidney function are well known. These 
patients should be compelled to carry only the lightest load possible 
when undergoing any surgical procedure and this becomes even 
more imperative when this procedure involves the urinary system. 
The anesthesia by inhalation which does the least amount of 
damage is nitrous oxide and oxygen. Nitrous oxide and oxygen 
alone may not offer sufficient relaxation to permit of the performance 
of an efficient operation without the addition of ether or local 
anesthesia. Nitrous oxide and oxygen combined with local is the 
more desirable, and local anesthesia alone has in this field one of 
its best opportunities to exhibit all of its advantageous qualities, 
provided that under its use the surgical procedure may be carried 
out efficiently. Having in mind the preponderance of evidence 
showing that the absorption of novocain does comparatively the 
least damage to kidney tissue, as is true of its effects upon the 
tissues of the other vital organs, the method of choice has been 
the use of local anesthesia in all genito-urinary cases in which the 
operation could be completed with efficiency and without distress 
to the patient. 

The observation of R. Morain 1 that albumin appeared in the 
urine frequently after even small doses of novocain had been injected 
has not been confirmed to any great extent by others. The author’s 
research in this field, carried out in a large number of cases in which 
novocain-adrenalin had been injected in amounts varying from 0.5 
to 2 gm. showed the presence of albumin and casts only occasionally 
in cases which had shown normal urine before operation. 


1 Zentralbl. f. Chir., Leipsic, July 10, 1921, pp. 489 504. 


316 


SURGERY OF THE GENITO-URINARY SYSTEM 


A perusal of the literature and a fairly extensive observation 
of the work of other surgeons and their methods fail to reveal a 
great deal of enthusiasm for the use of local anesthesia in major 
genito-urinary surgery. The attitude shown by the authors of 
works upon local anesthesia has not until quite recently been such 
as to win many advocates to the method. The technic has now 
been developed to such a degree that by its use, when combined 
with proper strategy, almost any operation upon the genito-urinary 
tract may be performed under local anesthesia. The advantage of 
having a patient undergo an operation with a normal amount of 
fluid in his system, the avoidance of the deleterious effects of 
general anesthesia, the possibility of reducing shock, hemorrhage 
and trauma, are demands that can no longer be ignored if the patient 
is to be accorded the maximum of safety. 

Sacral anesthesia (Fig. 28, page 117) plus a suprapubic infiltration 
permit of the performance of almost any operation upon the 
bladder. Even transperitoneal operations upon the bladder, of 
whatever nature, may be carried out by means of a preliminary 
sacral anesthesia combined with an infiltration of the abdominal 
wall and an anterior splanchnic anesthesia, and may be performed 
in all cases in which a negative intra-abdominal pressure can be 
obtained. 

Operations upon the lower end of the ureter present the greatest 
difficulty. The most successful method in the author’s hands has 
been the infiltration block of the sensory nerves supplying the 
peritoneum, combined with sacral anesthesia and a liberal infiltra¬ 
tion of the periureteral tissues proximal to the field of operation as 
dissection carefully progresses. Calculi have been removed from 
every portion of the ureter, resections of the base of the bladder 
and uretero-vesical anastomoses have been performed under this 
plan, generally with the production of only a small amount of 
discomfort. The abolition of the reflexes of the abdominal muscles, 
tilting of the table, steady, continuous retraction, perfect exposure and 
the avoidance of speed are prime essentials which favor local anesthesia. 

It is possible that the performance of operations upon the kidney 
and ureter under local anesthesia will not become common on 
account of the somewhat complicated technic, but the author’s 
experience leads him to conclude that patients with crippled cardio¬ 
renal systems should, whenever possible, have the benefit of this 
method. 

LOCAL ANESTHESIA IN SURGERY OF THE KIDNEY. 

Nerve Supply.—The nerves to be blocked in kidney operations 
are the ninth, tenth, eleventh and twelfth thoracic and the ilio- 


LOCAL ANESTHESIA IN SURGERY OF THE KIDNEY 317 


hypogastric nerve (I, L.) to the skin and muscles (see Plate IX), 
plus the splanchnic nerves to the kidney. The nerves of the 
kidney itself are derived from the renal plexus of sympathetics 
which is formed by branches of the celiac plexus and ganglion, the 
aortic plexus and the lowest lesser splanchnic nerves. The renal 
plexus also communicates with the spermatic plexus, which accounts 
for pain referred to the testicle in some cases of kidney affection. 



Fig. 128 .—Surgery of the kidney; anesthesia technic; subdermal infiltration; 
secondary wheals from beneath and intercostal infiltration block. 


Technic of Anesthesia.—The thoracic nerves can be easily 
blocked. In order to reach and effectually block the nerve supply 
of the kidney the drug must be administered in the proper manner; 
that is, it must be given in sufficient quantities and in the correct 
location to produce anesthesia. A squirt here and there will not 

































318 


SURGERY OF THE GENITO-URINARY SYSTEM 


suffice. Layer-by-layer infiltration will also prove tedious and 
disappointing. Nerve blocking near the point of exit from the 
spine or an infiltration-block sufficient to build a wall of anesthesia 
between the central nervous system and the kidney are the methods 
which will give most satisfaction. In either of these procedures 
one must use a sufficient quantity of the drug to produce anesthesia, 
and as the area to be blocked is a comparatively large one, a con- 



Fig. 129.—Surgery of the kidney; anesthesia technic; infiltration and paraverte¬ 
bral block; sectional view of Fig. 128. 1, rib XII; 2, diaphragm; 3, liver; 4, adrenal 

body; 5, perirenal fat; 6, kidney; 7, perirenal fat. 

siderable amount of the solution is required. The author employs 
infiltration and infiltration block and avoids spearing for nerves 
whenever possible. With long, fine needles the area to be blocked 
is gone over methodically from one end to the other, concentrating 
of course in the region where the nerve trunks are known to lie. 
(Figs. 128 and 129.) 

In case it is desirable to follow the ureter down toward the bladder 
the skin may be anesthetized by a subdermal infiltration and the 















LOCAL ANESTHESIA IN SURGERY OF THE KIDNEY 319 


deeper tissues by a thorough blocking of the ilioinguinal and ilio¬ 
hypogastric nerves. 

In case a kidney operation precedes the operation upon the 
ureter it is not usually necessary to reinforce the anesthetic when 
dealing with the ureter. 

The Kidney. — Sensation.—It has been found that the freeing 
of the pelvis and ureter is not painful, though it may be made 
so if the dissection is roughly done or if the anesthesia is not 
perfect. Likewise, the division of the fibrous capsule and paren¬ 
chyma may be made without pain. The clamping of the vessels 
is painful unless the splanchnics are blocked. As soon as the vessels 
are exposed (and this exposure should be accomplished with the 
utmost delicacy) an infiltration should be made in the tissues sur¬ 
rounding them. In this manner the branches of the splanchnic are 
reached and in a few moments good anesthesia will obtain. One 
should, if possible, apply the proximal clamp first when double- 
clamping the pedicle to avoid causing a repetition of the disagreeable 
sensation which may occur if complete anesthesia has not been 
established. The ligation of the vessels after clamping is not 
painful unless traction is made upon the pedicle. 

All sensation may be removed from the kidney pedicle by the 
establishment of posterior splanchnic anesthesia under the method of 
Kappis (see page 12). However, it has been found unnecessary to 
employ this technic under infiltration and a strategy which gives a 
good exposure, combined with splanchnic infiltration after exposure. 

Incision.—For kidney operations some modification of the trans¬ 
verse incision of Pean has been found the most satisfactory (Fig. 
130). This incision may be extended toward the midline in 
front as far as one desires and curved upward from behind. In 
the “ close-coupled” body and in those in which the kidney lies 
high or is difficult to deliver, the twelfth rib may be divided with 
bone forceps and mobilized (Fig. 131). By uncovering the rib from 
without and cutting only part way through it, injury to the pleura 
may be avoided. The incision usually begins at the outer edge of 
the rectus and its posterior limit is the anterior border of the ilio- 
costalis lumborum (sacrolumbalis muscle), but it may be carried 
farther backward, if desired. In the actual exposure and mobiliza¬ 
tion of the kidney the approach through the fascia and fat is made 
from behind. Here more novocain-adrenalin can be introduced 
between the lumbar muscles and the kidney, provided there is any 
complaint on the part of the patient. The fatty capsule is cut rather 
than torn and the kidney freed by clipping the retaining tissues as 
they are held between forceps, all of the manipulations being made 
directly under the eye if possible. The absence of pain will allow 
sufficient relaxation of the abdominal wall so that the kidney may 


320 


SURGERY OF THE GENITO-URINARY SYSTEM 


be pushed forward into the abdominal cavity. Here, as in intra- 
peritoneal operations, perfect anesthesia will allow of relaxation 
of the abdominal walls and the contents of the abdominal cavity 
will gravitate to the opposite or lower side. This allows consider¬ 
able space in front through which the kidney may be viewed and 
manipulated. With the rib divided and retracted one can generally 
see the upperpole and slip a piece of tape about the pedicle (Fig. 131, 



also see Fig. 195, page 445). Some strategy may be required in 
difficult cases in order to deliver the kidney without too vigorous 
manipulation. To illustrate the point, one might mention the 
comparative ease with which the densely adherent kidney, sur¬ 
rounded by perinephritic inflammatory tissue, may be mobilized 
by subcapsular enucleation. Stripping the fibrous capsule from the 
kidney instead of attempting to enucleate the complete inflammatory 


























LOCAL ANESTHESIA IN SURGERY OF THE KIDNEY 


321 


mass will often convert an almost impossible situation into a com¬ 
paratively simple one. 

Delivery of the Kidney.—For the purpose of elevating the kidney 
from its bed the use of the gauze retractor (see Fig. 131) is most 
desirable. As soon as one pole of the kidney is freed the central 
point of a piece of tape or gauze may be carried beneath it. The 
other kidney pole may then be freed and the gauze carried beneath 



Fig. 131 .—Surgery of the kidney; twelfth rib divided; exposure; gauze 

tractor in use. 


the second pole. One may then, by twisting the ends of the tape 
upon each other, absolutely control the kidney. Tension of any 
desired degree may be exerted upon the tape, thus giving one 
complete control of hemostasis. The kidney may be lifted out of 
its pocket by this means even though only one pole can be grasped 
by the tape*. However, as a rule the tape may be slipped around 

both poles. 

n 

















322 


SURGERY OF THE GENITO-URINARY SYSTEM 


Report of Case No. 10221. 

W. W. G., male, aged fifty-five years, entered hospital January 3, 
1917. 

Diagnosis: Left nephrolithiasis; left ureterolithiasis. 

Operation: Left nephrectomy and left ureterectomy. 

Technic of Anesthesia: Paravertebral block. Local infiltration. 

The patient was given two preliminary hypodermics of J gr. 
morphin and cro g r - scopolamin one and two hours respectively 
before operation. Paravertebral anesthesia was established from 
the seventh thoracic to the crest of the ilium. The transverse Pean 
incision was made with its anterior extremity directed downward. 
The twelfth rib was divided. Exposure of the kidney which had, 
upon preoperative investigation, been found to be functionless, 
showed a greatly enlarged organ, with densely adherent peri- 
nephritic tissue. The fibrous capsule was, therefore, divided and 
a subcapsular enucleation of the kidney made. By means of the 
gauze tractor (see Fig. 131), the vascular pedicle was exposed and 
splanchnic anesthesia established. The stump was then painlessly 
divided and a greatly thickened ureter dissected free for a distance 
of 15 cm. Without reinforcing the anesthesia a low muscle splitting, 
extraperitoneal incision was made in the region of the internal 
inguinal ring. The lower end of the ureter was freed, and divided 
below the position of the ureteral calculus, which roentgenograms 
had demonstrated to be present. Paraffine drains were inserted. 

Note. — In this case the ureter was freed nearly to the bladder 
attachment, without reinforcing the anesthesia, and without pain 
to the patient. However, the greatest care was exercised in freeing 
the parietal peritoneum. 

Report of Case No. 14572. 

M. W. P., aged fiftv-two years, entered hospital November 19, 
1921. 

Diagnosis: Pyonephrosis and nephrolithiasis (left). 

Operation: Nephrectomy. 

Anesthesia: Infiltration block; paravertebral block. 

History: The patient weighed 105 kilograms and her blood- 
pressure averaged 225. She was in a very septic condition, her 
temperature ranging from 101 ° to 103°, with a pulse from 100 to 120. 
Cystoscopic investigation revealed pyonephrosis and roentgen rays 
showed kidney stones. 

Anesthesia: Infiltration block, using 180 cc of a 1 per cent novo¬ 
cain-adrenalin solution. A subdermal infiltration was made first 
along the line of incision, which was transverse. A subdermal 
infiltration was then made 8 cm. lateral to the midline, extending 


THE URETER 


323 


from the seventh rib to the ilium. This was followed by a para¬ 
vertebral infiltration block (Fig. 129, page 318). 

The twelfth rib was mobilized. The kidney, with fully 2 to 3 
cm. of perirenal fat which was densely adherent on account of 
a marked perinephritis, was mobilized and elevated by means of a 
gauze tractor, and splanchnic anesthesia established. Three 
clamps were placed upon the pedicle and the kidney, which was 
the size of a cocoanut containing pus and a number of stones, 
was removed. The patient was given 2000 cc of a saline with yg- 
per cent novocain solution hypodermically twice a day following the 
operation, and she made an uneventful recovery. 

The following case illustrates the use of local anesthesia in acute 
kidney conditions: 

Report of Case No. 14206. 

M. H. D., aged twenty-one years, entered the hospital on Mav 15, 
1921. 

Diagnosis: Ruptured kidney with infected hematoma. 

Operation: Incision, drainage and suture of the kidney. 

Anesthesia: Local infiltration block. 

History: The patient had been injured in a motorcycle accident. 
He was extremely tender in the region of the left kidney and his 
urine showed a large amount of blood. His pulse, which was 90 
upon his entrance into the hospital, rose to 115 in twelve hours. 
The following day his pulse was 120 and his temperature 100; he 
had a severe chill, and the pain in the region of the left kidney was 
severe. 

Technic of Anesthesia: A classical infiltration was made, using 
150 cc of a 0.7 of 1 per cent novocain-adrenalin solution (Fig. 128, 
page 317). 

A transverse incision was made and a retroperitoneal hematoma 
opened and drained. One liter of dark, clotted blood and urine 
was evacuated. The kidney presented at the base of the cavity 
and showed a transverse rupture at about the midline. By means 
of perfect retraction, a good light and a long needle holder the 
two halves of the kidney were sutured together with chromicized 
gut without disturbing the organ. Drainage tubes were introduced 
and the wound closed. 

The boy made an uneventful recovery and presented normal 
urine within two weeks after the operation. 

THE URETER. 

Calculi.—The author has in a number of instances exposed the 
ureter under local anesthesia. The abdominal wall has been 


324 


SURGERY OF THE GEN 1T0-URINARY SYSTEM 


incised after a direct infiltration plus an infiltration block well above 
the point at which the exposure is to be made. As soon as the 
peritoneum is reached it is carefully infiltrated as are the tissues 
behind the peritoneum in the region of the psoas muscle. The 
patient is tilted laterally, and by means of a negative intra¬ 
abdominal pressure, exposure is facilitated. We have removed 
ureteral stones from every portion of the ureter under local anes¬ 
thesia by the use of this method. Stones lying near the distal end 
of the ureter are most difficult to reach by this method and the 
attempt should be preceded by the establishment of a sacral anes¬ 
thesia. (See Case No. 10221, page 329.) 

In April, 1918, the author 1 described a method of removing calculi 
from the distal end of the ureter under the use of local anesthesia, 
as follows: 

“While the exposure of the lower half of the ureter by the extra- 
peritoneal route for the purpose of removing calculi is generally 
referred to as a simple procedure, observation of a number of 
operations performed by surgeons of repute leads to the conclusion 
that this operation may, and in fact does, at times present diffi¬ 
culties which are embarrassing. This is especially true in obese 
patients and, more particularly, when stones are located well down 
toward the bladder. Within the last few months a surgeon of 
renown was observed to labor quite strenuously for a period of 
half an hour trying to locate the ureter. Bands of tissue were 
incised three or four times under the impression that the ureter 
was being opened before it was finally definitely located. This is 
not at all an uncommon experience. Furthermore, the manipula¬ 
tions required in order to identify and free the ureter will in many 
instances dislodge the offending stone, thus complicating matters 
and making an upward or downward chase necessary. 

“With the peritoneum open, there is no difficulty in locating 
the lower half of the ureter. With the pelvis free, one needs only 
to await one vermicular wave of the ureter in order definitely to 
locate it, and stones can usually be distinguished at a glance. It 
has been shown that transperitoneal cystotomy is a safe procedure. 
Transperitoneal ureterotomy should be equally safe. The opening 
of the peritoneal cavity allows one to deal with intraperitoneal 
pathology where indicated and, in the author’s opinion, simplifies 
the technic. This is especially true for stones located in the lower 
third. 

“ Technic.—The median incision is made just above the pubes and 
the pelvis is freed of intestine and carefully coffer-dammed with 
gauze. The vermicular wave of the ureter is watched for and the 

1 Robert Emmett Farr: The Removal of Calculi from the Lower Ureter by the 
Transperitoneal Route. Am. Jour. Urol., April, 1918, 


THE URETER 


325 


location of the stone determined. The peritoneum is then incised 
mesially to the ureter and the latter elevated by the use of uterine 
tenaeula. A urethral sound or curved forceps is then directed 
beneath the peritoneum external to the ureter, freeing it from the 
lateral wall. A stab-wound through the anterior abdominal wall 
is then made to meet the sound, and a cigarette drain inserted down 
to the ureter extraperitoneally. After the extraction of the stone 
and closure of the ureter the peritoneal wound is everted with 
catgut and the abdominal wall closed.” 

Grave Surgical Problems.—The following cases, on account of 
the grave surgical problems which they presented, are reported 
somewhat in detail. They illustrate in a graphic manner not only 
the necessity of giving a crippled patient every available chance, 
but as well the satisfaction with which such problems may be 
solved by the use of local anesthesia. 


Report of Case No. 8229. 

S. J. A., aged fifty-two years, entered hospital on March 3, 1915. 

Diagnosis: Left ureteral lithiasis; pyoureter; pyonephrosis. 

First Operation: Ureterotomy (left). March 6, 1915. Roentgen- 
ray examination showed three shadows at the level of the anterior 
superior spine. The ureteral catheter showed one of these to be 
within the ureter. 

Technic of Anesthesia: Direct infiltration of abdominal wall with 
120 cc of a 0.5 per cent novocain-adrenalin solution. 

A 15 cm. oblique incision down to the peritoneum was made. 
The anesthesia was reinforced here, infiltrating the peritoneum, 
which was then stripped inward, exposing the ureter. Two peri¬ 
ureteral calculi were removed, the ureter opened and one large cal¬ 
culus removed from its lumen. 

A ureteral catheter was inserted, passing upward to the kidney 
and the wound partially closed. The patient was allowed to return 
home for a month while his condition, which had been extremely bad, 
greatly improved. Upon his return all excretion from the left 
kidney was discharged through the drainage wound. An effort to 
reestablish the ureteral tract showed that it was impossible at this 
time to introduce a ureteral catheter into the left side. It was 
likewise impossible to pass a catheter from above through the 
ureter into the bladder. 

Second Operation: Suprapubic cystostomy, April 10, 1915. 

The bladder was opened under an infiltration, using 60 cc of a 0.5 
per cent novocain-adrenalin solution, and the ureteral meatus was 
dilated. A catheter was then passed up along the ureter into the 
kidney and out through the suprapubic opening and the ureteral 


326 


SURGERY OF THE GENITO-URINARY SYSTEM 


sinus was allowed to close. The catheter was withdrawn in ten 
days and the patient remained in excellent health for fourteen 
months, when he began to develop pain in the left kidney and 
showed signs of sepsis. Cystoscopic examination showed that it 
was impossible to pass a catheter by the site of the former ureter¬ 
ostomy wound. The secretion from the left side at this time was 
almost entirely purulent in nature. Nephrectomy was therefore 
decided upon. 

Third Operation: June 1, 1916, nephro-ureterectomy. 210 cc of 
a 0.5 per cent novocain-adrenalin solution were used as a paraver¬ 
tebral infiltration block, and a large adherent pyonephrotic left 
kidney and ureter removed. 

The patient made a splendid recovery and has remained entirely 
well. 

Note .—This case illustrates the fact that the ureter may be 
operated upon under local anesthesia even under the most adverse 
circumstances, provided the peritoneum is infiltrated when encoun¬ 
tered, and provided the paravertebral block has been carried down 
sufficiently far to include the ilioinguinal and iliohypogastric nerves. 
Ureterectomy may be accomplished during the nephrectomy 
operation without especially increasing the difficulties from the 
anesthesia standpoint. 

The following case presented even greater difficulties. 

Report of Case No. 14391. 

G. J., aged fifty-nine years, maximal weight 80 kgm., present 
weight 56 kgm., entered hospital September 9, 1921. 

Diagnosis: Double hydropyo-ureter; functionless left kidney. 

Operations: (1) Cystostomy; (2) vesico-ureteral anastomosis; (3) 
nephrectomy. 

Anesthesia: Sacral block; local infiltration: Paravertebral block. 

History: Seven years ago patient began having difficulty in 
emptying bladder. Later he began to have increased frequency. 
Five years ago he visited a clinic, and a diagnosis of cystitis was 
made. Medicine and irrigation relieved the condition somewhat. 
Two months before he came under observation he began to have 
more difficulty in emptying the bladder, and four weeks later was 
once more examined, when a cystoscopic examination was made at 
the same clinic. A diagnosis of chronic cystitis and some disease 
of the sacral nerves was made. 

On the patient’s entrance to the hospital, the bladder was found 
distended with urine, and was emptied by the gradual method. 
The prostate was not enlarged. The urine contained blood and 
pus. A cystoscopic examination, under sacral anesthesia, showed 


THE URETER 


327 


the following: Chronic cystitis; golf-hole ureter on the left, contracted 
'white meatus on the right. I reteral catheterization resulted in the 
withdrawal of blood and pus from both ureters. 

Pyelograms and ureterograms showed: Double pyonephrosis, 
double pyoureter. 

The right ureter was dilated by the simultaneous introduction 
of two catheters. After the first successful attempt it was found 
impossible to introduce an instrument of any kind into the left 
ureter. 

The patient was drowsy and uremic from the time he entered 
the hospital, and the phthalein output varied from day to day, 
averaging between 20 and 30 per cent. 

After dilation of the right ureter the patient improved somewhat. 

First Operation: Five weeks after admission. Suprapubic cvstos- 
tomy. On October 15, 1921, a suprapubic cystostomy was done 
under local infiltration, which had been preceded by sacral 
anesthesia. The right ureter was widely dilated with a series of 
urethral sounds. An effort was made to enter and dilate the left 
ureter, but it was unsuccessful, and, on account of the patient s 
condition, further operative measures were not attempted. The 
patient’s condition greatly improved. 

Second Operation: Vesico-ureteral anastomosis. On November 5, 
1921, almost two months after entrance, the left ureter was exposed 
extraperitoneally under local anesthesia, and an effort made to 
introduce an instrument into the bladder, from above, through the 
ureter. This effort being unsuccessful, a dressing forceps was 
introduced through the cystostomy wound and made to impinge 
upon the bladder fundus, which was then incised and a catheter 
drawn through, with its end projecting through the cystostomy 
wound. The ureter was then opened at a favorable point above the 
stricture, and the upper end of the catheter inserted well into the 
dilated portion of the ureter. A vesico-ureteral anastomosis was thus 
established by anchoring the ureter to the bladder wall with chromi- 
cized gut. The first ureteral incision was then closed and the 
incision in the abdominal wall closed, after cigarette drains had 
been inserted. 

The patient rapidly recovered. The catheter was withdrawn in 
ten days and the suprapubic wound healed. The patient gained 
16 kgm., and weighed 73 kgm. five weeks after leaving the hos¬ 
pital. 

On April 1, 1922, the patient began to have attacks of left-sided 
colic, temperature rising to 104° and accompanied by rigors. 

Fie reentered the hospital April 17, 1922. 

The function of the right kidney at this time was 25 per cent by 
the phthalein test and on April 27, 1922, was 30 per cent. His 


328 


SURGERY OF THE GENITO-URINARY SYSTEM 


intake averaged between 3200 and 3500 cc and output 2700 cc. 
The left kidney was practically functionless. Accordingly a left 
nephrectomy was performed notwithstanding the presence of a 
greatly crippled right kidney. 

Diagnosis: Double hydropyo-ureter; functionless left kidney. 

Third Operation: Left nephrectomy, April 27, 1922. 

Anesthesia: Local infiltration block, 180 cc of a 1 per cent novo¬ 
cain-adrenalin solution along the line of incision which was trans¬ 
verse, combined with paravertebral from the seventh to the twelfth 
thoracic. The patient received one preliminary hypodermic of 
morphin sulphate gr. J with 2 cc of 25 per cent magnesium sulphate. 

A transverse incision was made with a vertical limb posterior. 
The twelfth rib was divided. Excellent exposure was obtained and 
the kidney was mobilized by sharp dissection, splanchnic anesthesia 
being introduced along the pedicle under direct vision. 

The ureter was followed down for several inches and its stump 
ligated. The wound was closed with drainage. The patient had 
but slight reaction and the lowest intake was 2000 cc and output 
1400 cc in twenty-four hours. He gained rapidly. The phthalein 
remained about 25 per cent, the blood chemistry was normal and 
he was discharged May 16, 1922. He now weighs 80 kgm. 

THE BLADDER. 

Cystoscopy.— The necessity for the use of anesthesia in the per¬ 
formance of cystoscopic examinations would seem to be a matter 
of temperament with the individual who is to carry out the pro¬ 
cedure. As a rule the suffering is not considered sufficiently great 
to justify the use of general anesthesia. When general anesthesia 
is employed the rapid excursions of the bladder to and fro resulting 
from respiratory efforts of the patient may render the examination 
more or less difficult. It is a pleasure to note that cystoscopists 
are experiencing a change of heart in relation to the amount of grief 
which these sufferers should be compelled to endure. The demand 
for a cystoscopic examination is in itself usually evidence that 
infection or some other condition which tends to increase the 
sensitiveness of the bladder and urethra is present in the genito¬ 
urinary tract. It is well known that the simple passage of a sound 
in the male urethra may cause a patient to faint. Most surgeons 
would not think of performing any other operation which would 
bring about such a result without anesthesia. Also, it is well to 
remember that the difficulty of making a cystoscopic examination 
or catheterizing of the ureters is greatly increased by the mis¬ 
behavior of a patient who is undergoing pain. In case the bladder 
is the seat of disease, as in the presence of cystitis, especially the 


THE BLADDER 


329 


tuberculous variety, this organ will show a high degree of irritability. 
Its dilatation with fluid will be difficult on account of the spasm of 
the bladder and abdominal rigidity and in many other ways the 
examination may prove difficult and greatly handicap the cystos- 
copist. Six years of experience with sacral anesthesia (Fig. 
28, page 117) has convinced the author that its use is indi¬ 
cated in these cases, almost without exception, especially for the 
purpose of making the first and second examinations. After 
repeated examinations the bladder becomes more tolerant and a 
satisfactory examination may be made after the instillation of 
(30 cc of a 2 per cent novocain-adrenalin solution thirty to forty 
minutes previous to the time of examination. The ideal local 
conditions prevailing under a perfect sacral anesthesia make this 
form of anesthesia appear to the author the one of choice for cysto- 
scopic examinations. It is to be hoped that this method of 
anesthesia will be shown to be safe and that the margin of error in 
its establishment will decrease with further experience. 

Suprapubic Cystotomy.—Method of Opening Bladder.—In order 
to insure an added degree of comfort in all cases in which the 
catheter can be introduced, the opening of the bladder is preceded by 
a thorough irrigation and emptying of this viscus. Before the 
draping of the patient the bladder is therefore emptied. To 
the outer end of the catheter is attached a rubber tube which 
extends down between the limbs to the level of the patient’s feet, 
at which point a rubber bulb is attached. As the space of Retzius 
is exposed the bladder may be inflated with air in order to facilitate 
the dissection. The added comfort to the patient which results 
from maintaining a dry field is much appreciated. 

Technic of Anesthesia.—The method described in Chapter V, 
page 149, should be followed. With long, fine needles the anes¬ 
thesia should be carried down to or even through the bladder wall 
before the incision is made. The base of the infiltrated area should 
be wide, going well out to either side of the bladder wall and the 
needle point should be carried to the pubic bone and beneath it 
when anesthetizing the lower end of the field. As the bladder wall 
is exposed it may be infiltrated, provided the anesthetic has not 
already reached it. 

The operation for the removal of vesical calculi is a simple pro¬ 
cedure under infiltration anesthesia. The following case is typical. 

Report of Case No. 10221. 

W. W. G., male, aged fifty-five years, entered hospital June 5, 

1917. 

Diagnosis: Vesical calculus. 


330 


SURGERY OF THE GEN 1TO-URI NARY SYSTEM 


Operation: Suprapubic cystotomy; removal of calculus. 

Technic of Anesthesia: Suprapubic infiltration. 

No preliminary hypodermics were given. A transverse infiltra¬ 
tion, using 90 cc of a 0.5 of 1 per cent novocain-adrenalin solution, 
was made. The bladder was opened after distention with air and 
a stone the size of a hen’s egg was removed. 

One may remove calculi of moderate size through a suprapubic 
stab wound with the cystoscope as an aid, as shown in the following 
excerpt from The Urologic and Cutaneous Review. 1 

“Opinions regarding the most satisfactory manner of removing 
calculi from the bladder are as yet quite diversified. Small stones 
may be removed through the urethra, especially in the female, 
whose urethra may be easily dilated to a considerable size. Very 
large stones must be crushed or delivered through an adequate 
incision in the wall of the bladder. The crushing operation is not 
entirely satisfactory; if done without general anesthesia it is a 
rather severe ordeal for the patient, and, in any event, a possible 
nucleus may be left for the formation of new calculi in its wake, as 
one cannot be certain that all particles have been washed out. 

“On account of their great size, or because of such conditions in 
the bladder as diverticula, encrusted mucosa, or a state of the 
mucosa which renders visualization impossible, a certain per¬ 
centage of calculi demand cystotomy. There is, however, especially 
in the male, rather a large proportion of cases in which the stones 
are of moderate size and the condition of the bladder sufficiently 
healthy that the simple removal of the stones, without crushing, 
and with the minimum injury to the patient, both locally and 
generally, is desirable. It is for the handling of this class of cases 
that the following technic has been suggested. 

“ Technic.— The patient is prepared as for cystoscopy with the 
addition of a suprapubic shave. About an hour before operation 
the bladder is irrigated, and about 2 ounces of 1 per cent novocain 
left in situ after a thorough emptying of the viscus. Suprapubic 
infiltration, including all layers of the abdominal wall and the 
anterior wall of the bladder, is made over an area about three inches 
in diameter. A cystoscope is then introduced, the bladder dilated 
and orientation established. A stab-wound is then made just above 
and as close as possible to the pubic bone. With an ordinary or 
stone-grasping forceps this stab-wound is dilated to the approximate 
size of the stone which, under the guidance of the assistant looking 
through the cystoscope, is easily grasped and withdrawn. The 
procedure is so easy and can be done so quickly, that collapse of the 
bladder from the escape of the fluid through the suprapubic wound 

1 Robert Emmett Farr, M.D.: A Simple Method for the Removal of Moderate 
Size Vesical Calculi; The Urologic and Cutaneous Review, 1918, No. 5, 22. 


LOCAL ANESTHESIA FOR SUPRAPUBIC PROSTATECTOMY 331 

does not occur. Should there be any delay, the fluid may be 
replenished with sufficient rapidity to enable one to make use of the 
cystoscope. 

“ lhe advantages of this procedure are that it is relatively safe, 
relatively painless and relatively simple. It inflicts upon the 
patient the minimum of trauma and the period of convalescence 
is brief.” 


LOCAL ANESTHESIA FOR SUPRAPUBIC PROSTATECTOMY. 

It is the author’s belief that suprapubic cystostomy as a prelimi¬ 
nary operation in the case of prostatic hypertrophy should usually 
be performed under local anesthesia. A simple infiltration of the 
abdominal wall along the proposed line of incision is all that is 
required as stated above. 

Allen and others have successfully performed prostatectomy 
under local anesthesia by means of an infiltration of the prostatic 
capsule immediately after the bladder has been opened. In 
establishing anesthesia of the prostatic region, Allen protects the 
rectal mucosa by the means of a finger inserted into the rectum. 
This technic necessitates the introduction of a finger into the 
rectum and restricts the operator to the use of one hand for the 
purpose of making the infiltration. 

The author has performed a number of prostatectomies under 
infiltration of the prostatic capsule, but during the past six years 
has made use of sacral anesthesia (see Fig. 28, page 117) as a pre¬ 
liminary to the suprapubic infiltration and has been gratified in 
obtaining by this method practically perfect anesthesia in every case. 

For a number of years narco-local anesthesia was used in combina¬ 
tion with topical applications and suprapubic infiltration. (See 
Case No. 7289, page 335.) 

The author’s experience has been confined largely to the removal 
of the prostate through the suprapubic route and during recent 
years this procedure has followed the preliminary cystostomy in 
nearly every instance. 

Sacral Anesthesia.—After the introduction of from 90 to 120 cc 
of a 1 per cent novocain-adrenalin solution into the sacral canal 
(see Fig. 28, page 117), the suprapubic infiltration is made. 

The following description relates to the performance of a supra¬ 
pubic operation under the method that we have been using during 
the past six years. It has worked out very satisfactorily. 

Technic of Infiltration.—It is perhaps best to enlarge the bladder 
opening in these cases after making a circumferential infiltration 
according to Hackenbruch, as the tissues in the region of the 


332 


SURGERY OF THE GENITO-URINARY SYSTEM 


previously made cystostomy opening are inflamed and possibly 
somewhat infected. 

The initial wheal is made from beneath after introducing the 
needle through the raw surface of the preliminary cystostomy 
opening and carrying it along beneath the skin laterally for about 
5 or 6 cm. By this maneuver and by making all additional wheals 
from beneath we may establish the circle of infiltration about the 
proposed incision without producing pain. The patient is placed 
in a moderate Trendelenburg position and wire-spring retractors 
are inserted into the wound in the bladder, which should be of 
sufficient size to allow a perfect view of the interior of the bladder. 
A negative intra-abdominal pressure will allow the bladder to dilate 
to its full capacity and good illumination will bring about the 
visualization of the field. 

In not a single case has there been the slightest sensation of pain 
during the removal of the gland. It is desirable in these cases to 
avoid the introduction of the finger into the rectum and, in order to 
obviate the necessity of using the rectal finger, the prostatic retractor 
(Fig. 18, page 106) has been devised. Figs. 132 and 133 illustrate 
the modus operandi of this instrument. The dissection may be 
carried out without making great traction, provided the gland is 
gently elevated. Long, curved scissors are used in the enucleation. 
The anterior portion of the gland is best freed by an elevator (Fig. 
21, page 108) or by the use of the index finger. Following this 
technic no case has shown a pulse-rate above 90 while upon the 
operating table and, as a rule, the pulse has remained at about 70 
throughout the operation. 

Prostatic Retractor.—The following is the author’s description of 
the prostatic retractor which appeared in Surgery, Gynecology and 
Obstetrics, in November, 1920: 

“The first manipulation of a surgeon when doing a suprapubic 
prostatectomy is to place one, or more often two, fingers of one hand 
in the rectum in order to aid the enucleating finger of the other. 
There is no question but that asepsis is more easily preserved and the 
technic of the operation more refined when the rectal manipulation 
is eliminated. In addition to this factor, the rectal dilatation 
markedly interferes with a smooth anesthesia. If general anes¬ 
thesia is used, a deeper narcosis is necessary upon dilating the 
sphincter. Under local anesthesia the introduction of the fingers 
into the rectum is a serious handicap. 

“The instrument which the author has devised will effectually 
do all and even more than the rectal finger can do, thus eliminating 
the necessity of the latter. 

“The prostatic retractor, closed (Fig. 132), is introduced into the 
internal urethra for a distance depending upon the approximate 


LOCAL ANESTHESIA FOR SUPRAPUBIC PROSTATECTOMY 333 

size of the prostate. The prongs are then opened (Fig. 133), taking 

hold in the gland tissue, by turning the circular top of the instru¬ 
ment. 

I lie accompanying figures demonstrate clearly the modus oper- 
andi of the retractor. YY ith it in place the prostate may be elevated 



Fig. 132.—Surgery of the prostate; application of prostatic retractor closed; 

instrument introduced into urethra. 


to any degree that is compatible with its mobility, and the enucleation 
can be made largely under direct vision. Scissors dissection, done 
directly under the eye, may be advantageously used to expose one- 
half or two-thirds of the gland, after which the remaining portion 
may be freed by the enucleating finger or hook (Fig. 21, page 108), 


































































334 


SURGERY OF THE GENITO-URINARY SYSTEM 


“ Further experience may show that the prongs of the instrument 
may need to be modified as regards their size and shape. However, 



Fig. 133.—Surgery of the prostate; application of prostatic retractor; retractor open 

and elevating prostate. 
































































































































LOCAL ANESTHESIA FOR SUPRAPUBIC PROSTATECTOMY 335 


the first model has proved very satisfactory and has greatly 
facilitated operations which have been done entirely under local 
anesthesia.” 

In the following case, infiltration of the peri-prostatic tissues 
was necessary in addition to narco- and topical anesthesia as no 
preliminary sacral anesthesia had been established. 


Report of Case No. 8936. 

L. N., aged seventy-three years, entered the hospital December 
14, 1915. 

Diagnosis: Prostatic hypertrophy. 

Anesthesia: Local infiltration and narco-local. 

History: Had had frequent urination continuously for the past 
five years, and had had several attacks of retention of urine, for 
which he had been catheterized. 

Rectal examination showed a rather large, hard and somewhat 
nodular prostate. 

First Operation: Suprapubic cystostomy was made under an 
infiltration of quinine and urea hydrochloride, using J of 1 per cent 
solution. Eleven days later a prostatectomy was performed. 
Patient was given f gr. morphin and gr. scopolamin two hours 
before and the dose repeated one hour before the operation. 

Second Operation: Prostatectomy. Anesthesia was narco-local 
and infiltration of prostatic capsule, using quinine and urea hydro¬ 
chloride J of 1 per cent. The prostatic capsule was infiltrated and 
the enucleation of the gland was begun. The patient complained 
of pain and novocain-adrenalin solution was then injected to 
reinforce the anesthesia. The prostate was removed with difficulty, 
although without pain to the patient after the injection of the 
novocain-adrenalin solution. Microscopic examination showed the 
gland to be adenocarcinoma. 

Note .—In this case both the introduction of the quinine and urea 
hydrochloride solution and manipulation of the gland were painful. 
Relief was almost instantaneous after the use of novocain-adrenalin 
solution was begun. 

The following case is one in which the narco-local method, 
combined with topical application and infiltration, was used. This 
was before sacral anesthesia had been adopted as an adjunct. 


Report of Case No. 7289. 

B. F. M., male, aged sixty-six years, entered hospital April 
20, 1914. 



336 


SURGERY OF THE GENITO-URINARY SYSTEM 


Diagnosis: Prostatic hypertrophy; residual urine 400 cc, cathe- 
terized four times a day for two weeks when suprapubic prosta¬ 
tectomy was performed. 

Operation: Prostatectomy. 

Technic of Anesthesia: Narco-local anesthesia. Suprapubic infil¬ 
tration with novocain-adrenalin solution, using 60 cc of a 0.5 of 1 
per cent novocain-adrenalin solution. 

One hour before operation 120 cc of a 10 per cent quinine and 
urea hydrochloride solution had been deposited in the bladder. A 
hypodermic of J gr. of pantopon and 2 iro scopolamin was given three 
hours, and again one hour before operation. 

No infiltration of periprostatic tissues was done. The patient 
was extremely drowsy. There was no resistance and patient showed 
no signs of pain throughout the operation, the opportunity for 
which was perfect in every respect. A few hours after operation 
the patient withdrew the catheter, left the bed and walked about 
the room, without any apparent ill effects. This is one of the pos¬ 
sible objections to narco-local anesthesia. 

The following case shows the application of the method in extreme 
old age. 

Report of Case No. 10929. 

G. G. O., male, aged eighty years, entered hospital July 5, 1917. 

Diagnosis: Hypertrophy of the prostate gland. 

Anesthesia: Local infiltration block, sacral block. 

History: For a number of years patient has had intermittent 
attacks of retention of urine. The urethra admits a soft catheter 
and the residual urine is 300 cc. 

First Operation: Suprapubic cystostomy. 

Technic of Anesthesia: A classical infiltration block was made 
using 90 cc of a 0.5 of 1 per cent novocain-adrenalin solution. The 
bladder was opened with a negative pressure. Prostate was seen 
to project into the bladder on account of a greatly enlarged central 
lobe. Above the prostate was a well-marked diverticulum. The 
patient made a splendid recovery from his drainage operation and 
on July 19, twelve days after the preliminary cystostomy, supra¬ 
pubic prostatectomy was performed. 

Preliminary sacral anesthesia was established using 90 cc of a 
0.5 of 1 per cent novocain-adrenalin solution. The classical supra¬ 
pubic infiltration was then made with 90 cc of a 0.5 of 1 per cent 
novocain-adrenalin solution. 

The prostate was large in this case, and projected well into the 
bladder. It was removed by scissors dissection, being elevated 
by the use of the prostatic retractor. The highest pulse-rate 
recorded for this patient before, during and after the operation was 



LOCAL ANESTHESIA FOR SUPRAPUBIC PROSTATECTOMY 337 


88. He returned home in three weeks after the operation and 
remained well until four years later, when he began to suffer excru¬ 
ciating pain in the bladder, with frequent urination, pyuria and 
delirium. 

Third Operation: Cystoscopy and suprapubic cystostomy with 
removal of vesical calculus. 

The cystoscopy was made under sacral anesthesia April 22, 1921, 
90 cc of a 0.5 per cent novocain-adrenalin solution being used. At 
this time the patient was desperately ill, and the urine was loaded 
with pus. Cystoscopy showed a large vesical calculus, and the 
roentgenogram showed two calculi of approximately the same size 
as the one seen through the cystoscope. On April 28, 120 cc of 
a 0.5 per cent novocain-adrenalin solution was injected into the 
sacral canal. Following the introduction of this solution the patient 
had a slight convulsion, the pupils becoming dilated and respirations 
became rapid. The pulse did not change perceptibly. Supra¬ 
pubic infiltration was made about the old scar and the bladder 
opened. A dumb-bell stone was removed, one end of which pre¬ 
sented in the bladder, while the other end was encased in a divertic¬ 
ulum. The bladder was quickly packed and drained and the neck 
of the diverticulum dilated, and although the patient was delirious 
for three weeks he finally made a satisfactory recovery. 

The following case illustrates the use of local anesthesia in 
debilitated individuals where the margin of safety is extremely 
small. 

Report of Case No. 14505. 

C. W., male, aged seventy-seven years, entered the hospital 
September 28, 1921. 

Diagnosis: Prostatic hypertrophy. 

Anesthesia: Local infiltration; sacral block. 

History: The patient was delirious. There was residual urine 
to the amount of 800 cc. His liquid intake was 3500 cc and his 
output 2500 cc. The bladder was emptied gradually. One week 
after entering the hospital his blood chemistry showed urea nitrogen 
36.4 mgm. per 100 cc, creatinine, 3.06 mgm. per 100 cc and sugar, 0.11 
per cent. His phthalein ranged between 24 and 40 per cent total for 
two hours. 

After nine days of intermittent catheterization a suprapubic 
cystostomy was performed. Following this operation his phthalein 
output remained around 40 per cent total for two hours. His 
intake was 3000 cc and his output 2500 cc. One week after the 
performance of the suprapubic cystostomy the patient became 
decidedly worse. His intake was 4200 cc and his output 1200. 
He was delirious. Three days later his intake was once more 3500 
22 


SURGERY OF THE GENITO-URINARY SYSTEM 


33S 


cc and his output 2500. He was drowsy most of the time. Two 
weeks after the suprapubic cystostomy he began to improve, and 
sixteen days after the operation he sat up in a chair. One month 
after the operation his intake averaged 3600 cc per day and his out¬ 
put 3100 cc. He had gained greatly in strength. His phthalein 
total output for two hours averaged 50 per cent. 

Technic of Anesthesia, First Operation: Local suprapubic infiltra¬ 
tion. 

Technic of Anesthesia, Second Operation: Sacral and infiltration, 
using 90 cc of a 1 per cent novocain-adrenalin solution. 

The bladder was opened through a vertical incision. The 
prostate was large and smooth. It was elevated by means of 
the prostatic retractor (see Figs. 132 and 133, pages 333 and 334). 
Although the gland was smooth, malignant disease was suspected 
because of the difficulty of removal. 

At the close of the operation the patient’s pulse was seventy. 
One-half hour after returning him to bed he had a severe chill. His 
urinary output the following twenty-four hours was 750 cc. The 
second twenty-four hours his urinary output was 2000 cc and his 
intake 3500 cc. A note shows that the patient’s condition on the 
second day was as before the operation. He sat up on the seventh 
postoperative day and made an uneventful recovery. Microscopic 
diagnosis, adenocarcinoma. 

PERINEAL PROSTATECTOMY. ABSCESS. 

Perineal prostatectomy may be done under a direct infiltration 
plus blocking of the pudic nerves or under sacral or parasacral 
anesthesia. Prostatic abscesses and suppurative infections of the 
seminal vesicles demand sacral, parasacral or general anesthesia. 
These patients are apt to be hypersensitive and apprehensive and 
the psychic factor plays a larger part in them than it does in cases 
where infection is not present. 

THE MALE URETHRA. 

Stricture.—Sacral anesthesia is the ideal anesthesia for operative 
work upon the urethra. Under its influence internal or external 
urethrotomies or dilatations may be performed. 

The instillation of solutions of novocain-adrenalin 2 to 4 per 
cent into the urethra will, if retained for a period of thirty minutes, 
offer sufficient anesthesia for the passage of sounds and the urethro¬ 
scope or even the cystoscope in cases in which the bladder is not too 
sensitive, as the result of disease. 

In urethral strictures sacral is perhaps the most satisfactory 
method by which anesthesia may be established. 


THE MALE URETHRA 


339 


Report of Case No. 12048. 


J. L., physician, aged forty-six years, 
1919. 


entered hospital May 10, 


Diagnosis: Multiple urethral strictures. 

Operation: Urethral dilatation. 

History: The patient complained of retention of urine. The 
urethra presented multiple strictures and filiforms were introduced 


with difficulty. 

Technic of Anesthesia: Sacral injection. 



adrenalin solution had been injected into the sacral canal. Fili¬ 
form bougies were introduced and a hollow sound was passed over 
one of these. The urethra was dilated up to No. 30, French scale, 
but the anesthesia would not permit of further increase. Six days 
later 45 cc of a 1 per cent novocain-adrenalin solution were intro¬ 
duced into the sacral canal and twenty minutes later the urethra 


was dilated to No. 32 French scale. The sound could be introduced 
only to the membranous portion. The patient was advised to 
have an external urethrotomy, but he asked to come in later for 
this operation. 

On July 7, 1919, he reentered the hospital, when 90 cc of a 0.5 
of 1 per cent novocain-adrenalin solution were injected into the 
sacral canal. This time a filiform bougie was passed into the 
bladder and the Otis dilator was passed over this guide. The 
stricture was dilated to No. 47 French scale. Sounds were then 
passed until the urethra admitted a No. 29 without difficulty. 
The anesthesia was ideal. 

On July 21, 1919, the patient refused to allow the passage of 
sounds because of the severe pain the attempt caused, and sacral 
anesthesia was once more administered. 75 cc of a 0.5 of 1 per 
cent novocain-adrenalin solution were used, and the urethra was 
dilated up to No. 30 French scale. The anesthesia was excellent. 

Note .—This patient, an intelligent physician, after his first 
experience insisted upon having sacral anesthesia established before 
submitting to further dilatations. 

We have occasionally found that anesthesia has been incomplete 
after using this technic, but generally when less than 60 cc of the 
novocain-adrenalin solution had been used. 


Report of Case No. 11334. 

S. G. M., aged nineteen years, entered the hospital February 5, 

1918. 

Diagnosis: Congenital urethral stricture. 


340 


SURGERY OF THE GENITO-URINARY SYSTEM 


Operation: Dilatation of urethra. 

Anesthesia: Sacral block. 

History: For the last four years he had had difficulty in voiding. 
Frequent attempts to pass sounds had been unsuccessful. A 
diagnosis of urethral stricture (congenital) was made. 

Technic of Anesthesia: 60 cc of a 1 per cent novocain-adrenalin 
solution were injected into the sacral canal, which was entered by 
the needle without difficulty. After twenty minutes’ anesthesia 
was still incomplete, but the patient submitted to a dilatation with 
the Otis dilator, which had been passed over a urethral bougie. 
This procedure caused him considerable pain. One week later 90 
cc of a 1 per cent novocain-adrenalin solution were injected into 
the sacral canal and numerous attempts were made to sound the 
urethra. The anesthesia was incomplete up to one hour, at which 
time a No. 30 French sound was introduced, with but slight pain 
to the patient. 




Fig. 134. —Circumcision; anesthesia technic. 
Proximal circumferential block. 


Fig. 135. —Circumcision; anes¬ 
thesia technic. Longitudinal infil¬ 
tration. 


THE PENIS. 

Nerve Supply.—The penis is supplied by the right and left nn. 
dorsalis penis, the deepest divisions of the pudendal nerve, arising 
from the second, third and fourth sacral nerves and the pudendal 
plexus (see Plate Xl\ ); and by the ilioinguinal nerve (first lumbar) 
which supplies the root of the penis. 






























THE PENIS 


341 


Circumcision.—The extremely sensitive areas are the frenum 
and the glans. One may make a local infiltration or a transverse 
block, as desired. 

We have employed both the direct infiltration in the region of the 
foreskin and the infiltration block at the base. Infiltration of the 
foreskin has proven satisfactory. The initial wheal is made near 
the base of the penis, the needle point carried distally beneath the 
skin and the foreskin “ballooned up” with the anesthetic solution 
(see Figs. 134 and 135). Adrenalin is withheld from these solutions 
and the “ballooning” of the foreskin renders the operation more 
simple than it would otherwise be. The vessels may be plainly 
seen and ligated, and the structures are so magnified that the 
introduction of sutures is facilitated. 

Amputation of the Penis for Malignant Disease.—The technic 
described in producing anesthesia for the operation for oblique 
inguinal hernia made bilaterally, with the addition of the blocking 
of the femoral on each side, will suffice for a complete dissection of 
the inguinal glands, and the additional blocking of the pudic 
branches will suffice for the amputation of the penis. (See Fig. 171, 
page 404.) 

Hypospadias.—This operation may be performed under a trans¬ 
verse blocking at the base of the penis with the addition of a sub- 
dermal injection of the scrotal wall, provided portions of this tissue 
are to be used in making the plastic. 

Varicocele.—The nerves involved in the operation for variocele 
are those lying over the region of the spermatic cord. 

The skin over this region is supplied by: (1) The lumboinguinal 
nerve (n. lumboinguinalis; femoral or crural branch of the genito¬ 
femoral) (I. II. L.) and the ilioinguinal nerve (n. ilioinguinalis) 
(I. L.) which supplies the skin of the thigh immediately below the 
ilioinguinal ligament. (2) The anterior cutaneous branch or hypo¬ 
gastric branch of the iliohypogastric nerve (n. iliohypogastricus) 
(I. L.), and the anterior division of the twelfth thoracic nerve 
supplying the hypogastric region above the ligament. (See Fig. 
160, page 380.) 

The spermatic cord is supplied by the external spermatic nerve 
(n. spermaticus externus) or genital branch of the genitofemoral 
(I. II. L.) which supplies the cremaster. The spermatic plexus 
from the sympathetic and pelvic plexuses as well as the genital 
branch of the genitofemoral are found in the cord. 

Skin Sterilization.—Operations in this region demand much care 
in the sterilization of the skin. It would seem to be preferable to 
make the skin incision above the base of the scrotum whenever 
possible. Irritating solutions should not be allowed to come in 
contact with the unanesthetized scrotal integument. Should it be 


342 


SURGERY OF THE GENITO-URINARY SYSTEM 


necessary to sterilize the scrotum it is well to use solutions that are 
non-irritating or to follow the plan suggested in Chapter XI\ under 
the description of the operation for inguinal hernia. In this manner 
the scrotum may be anesthetized before being sterilized. 

Technic of Infiltration.—A subdermal infiltration is made along 
the line of the proposed incision (Fig. 136). The injection is then 
carried down to the cord at the point where it emerges from the 
external inguinal canal. About 60 cc of solution are introduced, 
care being taken to keep the needle point constantly in motion. 
Vertical retraction during the making of the incision and exposure 



Fig. 136.—Varicocele; anesthesia technic; 
subdermal infiltration. 



Fig. 137.—Varicocele; anesthesia 
technic; blocking of genitofemoral 
branch. 


will serve to easily identify the tissues. As the cord appears 
anesthesia may be reinforced, otherwise manipulation may cause 
the patient discomfort (Fig. 137). 

Hydrocele.—Orchidectomy.—Vasectomy.—The sensory nerves in 
addition to those mentioned under “ Varicocele” which are involved 
in a hydrocele are as follows (see Fig. 138, also Fig. 160, page 380): 

Those of the scrotum are derived from: 

1. The ilioinguinal nerve (n. ilioinguinalis) (I. L.), supplying the 
upper part of the scrotum. 

2. The external spermatic nerve (n. spermaticus externus), a 































THE PENIS 


343 


branch of the genitofemoral (I. II. L.), supplying a small part of 
the scrotum. 

'). I he posterior scrotal branches (nn. scrotales posteriores) 
of the perineal nerve (n. perinei) which are terminations of the 
pudendal nerve (II. III. I\ . S.), and are also called the superficial 
peroneal nerves. (See Fig. 138.) 

4. The inferior pudendal branch (long scrotal nerve) of the 
posterior femoral cutaneous nerve (n. cutaneus femoralis posterior) 

(I. II. III. S.). 



Fig. 138.—Nerve supply of male perineum, scrotum and penis. 


Technic in Infiltration.—For this operation a subdermal injection 
is made along the line of the proposed incision and from this line 
is carried around the neck of the scrotum to a point well past the 
midline both on the anterior and posterior surfaces (Fig. 139). As 
soon as the sac is identified it is well to make a thorough infiltration 
near its neck and as soon as the cord is seen one may inject the 
spermatic plexus from the sympathetic and the filaments from the 
pelvic plexus as they course along with the cord. It has also been 
suggested that the injection into the sac of a few drops of con¬ 
centrated novocain solution might be desirable, as a preliminary, 
but the author has not found this technic necessary in his work. 















344 


SURGERY OF THE GENITO-URINARY SYSTEM 


All operations upon the scrotum, such as orchidectomy, vasectomy 
and the like, may be performed under this technic. 

Vasotomy.—Vasotomy may be done under a simple skin infiltra¬ 
tion along the scrotal wall at the appropriate point. The vas 
may be identified before or after anesthetizing the scrotal wall and 
brought to the surface by grasping it with the thumb and finger. 
A small amount of solution injected above the point at which the 
vas is to be opened will give one sufficient anesthesia for this opera¬ 
tion (Fig. 137). 



Fig. 139.—Hydrocele; anesthesia technic; subdermal infiltration. 

THE FEMALE GENITALIA (EXTERNAL). 

Nerve Supply.—The nerve supply to the external female genitalia, 
vagina and cervix is as follows (Fig. 141): 

The labia are supplied by the ilioinguinal (I. L.) and the posterior 
labial branches (nn. labiales posteriores; superficial peroneal nerves) 
of the perineal nerve (n. perinei), in turn coming from the pudendal 
nerve (II. III. IV. S.). 

The clitoris is supplied by n. dorsalis clitoridis, one of the deepest 
divisions of the pudendal nerve. 










THE FEMALE GENITALIA 


345 


1 lie vagina is supplied by the visceral branches from the third 
and fourth and sometimes the second sacral nerves communicating 
with the plexuses of the sympathetic (vaginal plexus), which is a 
part of the hypogastric plexus. 

r Ihe levator ani is supplied by muscular branches of the fourth 
sacral nerves. 

r lhe cervix is supplied by the hypogastric and ovarian plexuses 
and by branches from the third and fourth sacral nerves. 



General Considerations.—Methods of Obtaining Anesthesia.— 

The nerve supply (Fig. 140), with the exception of the hypogastric 
plexus, may be interrupted by the induction of sacral anesthesia, 
or by conduction anesthesia along the course of the nerves. Excel¬ 
lent anesthesia may be obtained by either method. Infiltration 
block, combined with direct infiltration, is perhaps the method of 
choice. The upper portion of the vagina and the uterus demand 
additional anesthesia and the infiltration of the tissues is all that is 
required. In case the dissection is carried extremely high when 
performing a perineorrhaphy one may expect complaint provided 
only the pudic nerves have been intercepted, and this should be 
anticipated and the anesthesia reinforced before causing the patient 



346 


SURGERY OF THE GENITO-URINARY SYSTEM 


pain. All work upon the uterus demands a circumferential block 
about the cervix and extending well up into the broad ligaments. 
A preliminary infiltration using a colored solution before opening 
the abdomen will give one much aid and one’s technic may be 
improved rapidly by this means. Sacral, parasacral or trans- 
sacral anesthesia are also entirely satisfactory for operations upon 
the female genitalia. The author prefers infiltration and infiltration 
block on account of the speed and simplicity with which it may be 
established, and it also admits but slight error. 



Fig. 141.—Lithotomy position. Comfort equipment of operating table, showing 
pillows, legholders and armholders. Insert: Shows patient draped; pneumatic 
injector in position: cut-off B hanging on special forceps. (See Fig. 142.) 


Psychic Considerations.—In performing surgical operations upon 
the female genitalia psychic considerations must assume an impor¬ 
tant role. In no other class of operations is the surgeon called upon 
to depart so radically from the routine commonly seen in hospital 
practice where patients are being operated upon while unconscious 
under general anesthesia. While the custom which prevails may 
perhaps be considered acceptable where general anesthesia is used, 
the use of local anesthesia demands the utmost vigilance in respect 
to shielding the patient from all unnecessary indignities which may 


































































































































THE FEMALE GENITALIA 


347 


result from careless manipulations or needless exposure. Bodily 
comfort is a prime essential. (Fig. 141.) Fig. 142 shows the cut¬ 
off-holding forceps (see Fig. 141 B). 

\\ File the establishment of local anesthesia is not difficult, the 
carrying out of any operative procedure upon the external genitalia 
of the female demands more than the simple prevention of pain. 
It requires the development of a system in relation to the care and 
management of these cases that will offer sufficient reassurance to 



Fig. 142.—Special hook forceps upon which cut-off is hung. (See Fig. 141, B.) 

overcome the normal and natural apprehension inherent in most 
women under such circumstances. Minute attention to detail 
and the careful exclusion of all sources of error in carrying out a 
properly established regime is absolutely essential. Attention to 
the various points enumerated on page 346 and Chapters III, page 
69, and V, page 135, applies here with special emphasis. 

Careful covering of the eyes, prevention of unnecessary exposure, 
the elimination of unnecessary noise, especially the prohibition of 
conversation on the part of visitors who may be present and the 
constant reassurances of a tactful psycho-anesthetist will usually 
suffice to reduce to a minimum the so-called psychic incompatibility 
which may be present in these cases. 















348 


SURGERY OF THE GENITO-URINARY SYSTEM 


The precautions detailed have not been suggested as a result 
of any untoward experience by the author, as in his hands local 
anesthesia has, as a rule, been more readily accepted by women 
than by men. It would seem, however, that too much care could 
not be exercised in offering these individuals every possible safeguard 
to the inherent modesty present in all normal women. 

Vaginal Examinations in Virgins.—Anesthesia for vaginal examina¬ 
tions and uterine or cervical operations in virgins or sensitive women 
who have not borne children, should be preceded by an infiltration 
of the labia laterally and of the posterior vaginal margin. In these 
individuals the introduction of instruments into the vagina and the 
dilatation of this organ for the purpose of exposing the cervix are 
usually the cause of considerable complaint which may be obviated 
in the above mentioned manner. A preliminary establishment of 
anesthesia of the perineum will allow, and in fact produce, a satis¬ 
factory dilatation of the vagina, so that the work upon the cervix 
or uterus may be carried on without embarrassment. 

This simple procedure will allow a vaginal examination to be 
made without discomfort and should an operation prove necessary 
it may be carried out at once without the necessity of repeating the 
anesthesia. 

A great deal of vaginal work must be performed in conjunction 
with and preliminary to abdominal work, and here the method has 
considerable advantage. The delay necessary in making prepara¬ 
tion for the abdominal operation always necessitates prolonging 
general anesthesia and time becomes a more or less important factor. 
Where novocain is used the element of time is relatively unimportant 
inasmuch as the patient is not inhaling an anesthetic during the 
period of preparation. While it is possible for a skilled anesthetist 
to reduce the amount of general anesthesia greatly during this 
period, the fact remains that but a comparatively small percentage 
of patients who are being operated upon today receive the benefit 
of such skill. 

The operations which present in this region are those upon the 
labia, clitoris, perineum, urethra, vaginal wall, cervix and uterus. 

Operations upon the Labia.—Cysts.—Neoplasms.—Abscesses. 

The Nerve Supply.—The nerve supply to the labia is derived from 
the ilioinguinal (n. ilioinguinalis) I. L.) anteriorly, and the posterior 
labial branches (nn. labiales posteriores; superficial peroneal nerves 
(II. III. IV. S.) of the pudendal nerve posteriorlv (Fig. 140, page 
345.) 

Technic of Anesthesia.—All operations upon the labia may be 
performed under direct infiltration or infiltration block. Labial 
cysts and other tumors, in the absence of malignancy, may be 


THE FEMALE GENITALIA 


349 


isolated from their nerve supply by an infiltration block. Cysts 
and abscesses of the glands of Bartholin may be incised or excised 
under an infiltration block, although in the presence of infection 
the use of sacral anesthesia may be desirable. Malignant disease 
of the labia, unless very limited in extent, is best carried out 
under the influence of sacral anesthesia. Careful attention should 
be paid to points detailed above, as this region demands special 
care in the prevention of pain and exposure. 

Operations upon the Clitoris.—The Nerve Supply.—The nerve 
supply of the clitoris is derived from n. dorsalis clitoridis, one of the 
deepest divisions of n. pudendus (II. III. IV. S.). 

This organ is extremely sensitive, and demands the most careful 
interruption of its nerve supply, provided its sensation is to be 
obtunded. The treatment of malignant disease here, as well as in 
the labia, unless very limited in extent, is best carried out under the 
influence of sacral anesthesia combined with infiltration block, 
described above. 

Operations upon the Perineum. — The Nerve Supply of the Peri¬ 
neum.—The perineum is supplied by the pudendal nerve and 
branches of the anococcygeal nerves (nn. anococcygei) (VI. V. S. 
1 Coccygeal), (Fig. 140, page 345). 

Perineorrhaphy. —Technic of Anesthesia.— The nerve supply 
of the perineum being so easily reached makes the anesthetization 
of this structure a simple procedure. The infiltration block should 
be wide and extensive. The technic for the establishment of local 
infiltration which permits of perineal repair is as follows: 

Infiltration Block .—An initial wheal is made just within the 
vaginal margin (Fig. 143), the needle point entering the vaginal 
mucosa as this area is not especially sensitive. From this point 
the needle is carried alternately beneath the mucosa of the respective 
labii to a point near the clitoris, a submucosal infiltration being made, 
(Fig. 144, A ). The needle is now introduced through secondary wheals 
which have been made in the mucosa from beneath, at points lateral 
to the vaginal outlet (Fig. 144, B and B'). The tissues are infiltrated 
as the needle advances. The triangular ligament is pierced as may 
be determined by its feeling of resistance, as well as by the fact 
that it is slightly sensitive and may elicit a complaint from the 
patient. Just beyond the triangular ligament a liberal supply of 
fluid is deposited, the needle being withdrawn and reintroduced 
in a slightly different direction until an area approximately the size 
of a walnut has been thoroughly edematized. This procedure is 
repeated on the opposite side. The anesthesia resulting from this 
injection is sufficient to permit of the most extensive plastic opera¬ 
tion one may be called upon to perform in this region. Complete 


350 


SURGERY OF THE GEN I TO- URINARY SYSTEM 




Fig. 144.—The perineum; anesthesia technic; A, labial and subdermal infiltration 

B and B r , points for blocking the pudic nerve. 


Fig. 143.—The perineum; anesthesia technic; initial wheal. 




Co ooL 










THE FEMALE GENITALIA 



lacerations demand that an additional infiltration be made external 
and posterior to the rectum. As an aid to the separation of the 
vaginal mucous membrane a fairly extensive infiltration may be 
made between the vaginal and rectal walls, “ballooning” up the 
septum it one so desires (Fig. 145). This technic has certain points 
of advantage, the tissues are rendered thicker and thus more 
distinct, and the vaginal and rectal walls are separated and hemos¬ 
tasis is abetted. 

Any type of operation may be performed and the anesthesia, 
provided it is insufficient, may be reinforced without stint. There 
are two stages of the operation during which reinforcement is most 



Fig. 145.—The perineum; anesthesia technic. “Blowing off” or separating vaginal 
from rectal mucosa, wire-spring retractor separates labia. 


apt to be required; first, when an extremely high separation of the 
vaginal mucosa along the anterior rectal wall brings one in contact 
with the higher group of nerves which supply this region—the 
hypogastric plexus—and which have not been reached by the 
original infiltration. Direct infiltration just beneath the vaginal 
mucosa is all that is required to meet this contingency. The 
second stage at which reinforcement may be required is during the 
application of the widest of the tension sutures which coapt the 
separated portions of the levator ani. An infiltration made external 
to the highest point at which the sutures are carried through the 
levator ani will result in complete and satisfactory anesthesia. Any 


352 


SURGERY OF THE GENITO-URINARY SYSTEM 


edematization which may have been produced by the infiltration 
will have disappeared sufficiently early so as not to interfere with 
the introduction of sutures and the completion of the operation. 

Operations upon the Cervix and Uterus.—Curettage. —The Nerve 
Supply.— The uterine cervix is supplied by the hypogastric and 
ovarian plexuses and by branches from the third and fourth sacral 


nerves. 

Technic of Anesthesia.— Sacral, parasacral, trans-sacral anesthesia, 
or infiltration block may be employed. 





Fig. 146.—Vaginal dilatation after anesthetizing. A and B, wire-spring retractors. 


Infiltration Block.— Here, as elsewhere, the main difficulty 
presents in obtaining exposure. A good position on the table, 
perfect light, good anesthesia of the vaginal outlet and intelligent 
retraction are essential aids in obtaining this exposure (Fig. 146). 
The cooperation of the patient may also be enlisted. The patient 
may be asked to raise the hips slightly, or to cough or strain, thus 
bringing the cervix into view. A long handled hook, or a Barrett 
tenaculum (Fig. 147), may be introduced without discomfort, and 
by its use the cervix may be deflected from one side to the other, 
bringing the various sulci into view. The cervix may be best 
anesthetized by a circumferential infiltration (Figs. 147 and 148). 

























THE FEMALE GENITALIA 


353 


1 rovided intrauterine work is to be done the infiltrating needle 
should pass well up laterally to the uterus, and approximately 30 cc 
of solution should be deposited in each broad ligament at a depth of 

2 to 4 cm. Under this anesthesia dilatation, amputation of the 
cervix and intrauterine operations may be carried out. 




Fig. 147. —The cervix and uterus. Anes- Fig. 148.—Vaginal anesthesia. Infil- 
thesia technic. Pericervical and broad tration of the anterior vaginal wall, 

ligament infiltration block. 


This case below is cited to show the application of local anesthesia 
in cases of retained placenta where the patient had become exsangui¬ 
nated : 

Report of Case No. 10036. 

L. C. G., female, aged thirty-three years, entered hospital August 
28, 1917. 

Diagnosis: Incomplete abortion. Secondary anemia. 

Anesthesia: Local infiltration. 

Operation: Removal of secundines. 

History: There had been an accidental abortion one week pre¬ 
viously, and the patient had been bleeding profusely ever since. 
Her hemoglobin was 42 per cent; she was extremely pale and her 
condition seemed hazardous. She fainted repeatedly before being 
taken to the operating room. 

Anesthesia: 40 cc of a 0.5 per cent novocain-adrenalin solution was 
used and a circular infiltration was made about the cervix which 
was large and edematous. 

After gentle dilatation the uterus was curetted with gauze upop 
23 



354 


SURGERY OF THE GENITO-URINARY SYSTEM 


the end of a dressing forceps. A large amount of material was 
scraped out. 

The operation under this technic was entirely painless and the 
patient made an uneventful recovery. 

Anterior Colporrhaphy.— Technic of Anesthesia .—This operation 
may be performed after making a rhomboid submucous infiltration 
(Fig. 148), and is facilitated by the “blowing up" process, or the 
depositing of an excessive amount of solution between the vaginal 
and bladder walls, a method similar to that described for peri¬ 
neorrhaphy (Fig. 145, page 351). When making this infiltration 
the needle point should be carried well laterally and should be 
directed posteriorly and away from the bladder wall. 

The Uterus. —Interposition Operation .—Infiltration Block.— Ordi¬ 
narily the cervix may be grasped without producing pain. How¬ 
ever, many patients do complain of pain when this procedure 
is attempted. It has, therefore, been my practice to produce a 
wheal before the cervix is grasped by the tenaculum. A good 
exposure will allow this. The technic for rendering the cervix 
and the uterine mucosa anesthetic is as follows: 

With a 10 cm. needle, a wheal is made to the right or left of the 
cervix (Fig. 147). The needle is then advanced from 3 to 5 cm. 
parallel to the midline of the uterus, or diverging somewhat, traction 
being made on the cervix the while. As the needle is withdrawn 
the fluid is allowed to escape into the parametrium. The direction 
of the needle is changed with each stroke and an effort is made to 
inject the tissues to each side of the uterus, 20 to 30 cc of solution 
being used. This procedure is repeated on the opposite side, when 
dilatation of the cervix may be accomplished. For operations on the 
cervix, exclusive of malignant disease, a ring of infiltration is made 
around the cervix in the vaginal vault, this infiltration being allowed 
to extend well into the tissues about the cervix throughout the entire 
circumference. 

Anesthesia. — The satisfactory performance of this operation 
under local anesthesia requires good anesthesia of the perineum 
and anterior vaginal wall and this may be obtained by the 
methods described on page 353; with the addition of a liberal 
infiltration between the cervix and bladder. The needle should be 
carried well up along the posterior bladder wall, reaching the 
peritoneum in this region. An excellent exposure is a prerequisite 
for the performance of this operation under local anesthesia. The 
only pain associated with its performance occurs when the uterus is 
delivered and traction is made upon the round ligaments. While 
able to prevent most of this pain by preceding the operation with a 
wide infiltration between the uterus and bladder one may be unable 
to prevent all the pain caused by traction upon the round ligaments 


THE FEMALE GENITALIA 


355 


at the time the uterus is being delivered. It is possible to block 
the round ligaments directly as they are brought into view, but thus 
far a means has not been developed by which they can be anesthetized 
before delivering the uterus. It would seem that one might block 
these structures from above by introducing the needle through the 
external inguinal canal, depositing a liberal supply of solution in the 
region where the round ligament emerges from the abdominal 
cavity. The uterus is best delivered by depressing the cervix into 
the hollow of the sacrum and applying small cat’s paw retractors, 
“hand-over-hand,” to the fundus of the uterus. Some strategy is 
required in order to carry out this procedure under local anesthesia 
but experience with more than a score of these cases with but a 
small amount of difficulty leads to the belief that a technic will soon 
be developed by which this operation will be performed with facility 
and dispatch under simple infiltration anesthesia. Under sacral, 
trans-sacral or parasacral anesthesia, the operation may also be 
performed with satisfaction. However, should it be found possible 
to establish the direct infiltration upon a practicable basis this 
would eliminate the more or less irksome technic required by the 
more complicated methods demanded by the establishment of 
sacral anesthesia. 


Report of Case No. 10032. 

Mrs. E. I). F., female, aged fifty-three, entered hospital August 
27, 1917. 

Diagnosis: Uterine prolapse, third degree with large vesicocele. 

Operation: Watkins interposition; perineorrhaphy. 

Anesthesia: Classical infiltration block using 45 cc of a 0.5 of 
1 per cent novocain-adrenalin solution in perineum. A circum¬ 
ferential block about the cervix was made, using 30 cc of the same 
solution. 

The patient noticed some distress during delivery of the uterus 
into the vagina. The round ligaments were blocked as soon as 
they appeared, 4 cc of novocain-adrenalin solution being used in 
each. The classical Watkins operation was performed. The 
perineum was then repaired by the split septum method. Anes¬ 
thesia was ideal. Patient ’s pulse was 80 at end of operation, and 
she had no postoperative nausea, vomiting or gas pains, and made 
an uneventful recovery. 

Report of Case No. 10290. 

Mrs. A. A. C., female, aged sixty-two years, entered hospital 
May 6, 1917. 

Diagnosis: Uterine prolapse (third degree); hemorrhoids. 


356 


SURGERY OF THE GEN 1T0-URINARY SYSTEM 


Operation: Interposition operation (Watkins); perineorrhaphy. 
Hemorrhoidectomy f gr. morphine and 4 - 5-0 gr. scopolamin given one 
hour before operation. 

Anesthesia: Classical infiltration block of perineum. A circum¬ 
ferential infiltration was made about the cervix, 120 cc of a 0.5 
per cent novocain-adrenalin solution being used. An especially 
liberal amount of the solution was deposited anteriorly. The 
cervix was amputated, the peritoneum opened, and the uterine 
body brought into view by depressing the cervical stump backward. 
The patient being in the moderate Trendelenburg position no 
intestine appeared in the incision. The fundus was delivered by 
means of small cat s paw retractors and the round ligaments were 
infiltrated as soon as they were visualized. The classical Watkins 
operation was performed. The perineum was then repaired. The 
pulse was 70 at the completion of the operation. 

A circumferential infiltration was then made about the rectum, 
and the sphincter moderately dilated. Hemorrhoids were removed 
by the clamp and cautery technic. 

This patient vomited once directly after the operation, but had 
no further nausea or vomiting throughout her convalescence, which 
was uneventful. 

Vaginal Hysterectomy.— Technic of Anesthesia.— Trans-sacral, 
parasacral, sacral (see page 117) or infiltration anesthesia may be 
used. We favor infiltration anesthesia over the other forms, and 
shall describe it in more or less detail. 

The author’s experience with vaginal hysterectomy is limited, as 
he much prefers the abdominal route for this work. However, 
occasionally patients are seen with uterine conditions for which it is 
deemed best to use the vaginal route. The performance of this 
operation under local anesthesia, while presenting difficulties, can 
be accomplished with entire satisfaction, provided certain principles 
be rigidly followed. The introitus should be anesthetized in order 
to allow relaxation of the vagina. In this manner one may have 
sufficient room in which to carry out the operation and the obtaining 
of an exposure will not be accompanied by discomfort to the patient. 
Perfect exposure, combined with a wide infiltration about the 
uterine cervix and extending well up into the broad ligaments will 
give splendid anesthesia. In making this block the exposure is 
facilitated by grasping the cervix with a tenaculum. In making 
the infiltration, one should not hesitate to carry the needle point 
sufficiently deep to obtain anesthesia of the peritoneal surface. 
The regions of the uterine arteries are the most sensitive. The 
infiltration between the bladder and uterus and between the rectum 
and uterus proves to be of advantage just as it does when used as a 
preliminary to abdominal hysterectomy. It serves to separate the 


MISCELLANEOUS OPERATIONS 


357 


uterus from the bladder and rectum and therefore, to reduce the 
liability of injury to the walls of these structures. As soon as the 
infiltration is completed and the cervix has been circumscribed by an 
incision in the vaginal vault, the peritoneal cavity is entered from 
in front. The incision should be liberal so that the uterus may be 
turned into the vagina without a great amount of traction. As 
soon as the round ligaments are seen they are liberally infiltrated 
with novocain-adrenalin solution. Traction upon the round liga¬ 
ments is the cause of distress and whenever possible this should be 
anticipated. Usually a liberal infiltration will eliminate complaint. 
The author has performed this operation a number of times since 
1907 and during recent years he has, by adhering to the above 
detailed technic, been gratified to find that in the majority of cases 
the operation could be completed with almost no distress. 

The following case will illustrate the manner of performing a 
vaginal hysterectomy by means of infiltration block alone, and also 
the benign effect of this method of treatment: 

Report of Case No. 9200. 

A. I. M., female, aged thirty-six years, entered the hospital 
October 15, 1916. 

Diagnosis: Cancer of the cervix uteri. 

Operation: Vaginal hysterectomy. 

Anesthesia: Local infiltration. 

History: This patient had been a victim of chronic Bright’s 
disease for a number of years. She had been bleeding constantly 
from the cervix and uterus and was in a rather critical condition. 
Her hemoglobin was 50 per cent. The cervix presented a cauliflower 
growth. The uterus was entirely free and easily brought to the 
introitus. 

Technic of Anesthesia: A wide circular infiltration was made about 
the cervix uteri, the needle being carried well up into the broad 
ligaments at every stroke, and 90 cc of a 0.5 of 1 per cent novocain- 
adrenalin solution were used. 

Operation: Vaginal hysterectomy. Quinine and urea hydro¬ 
chloride, 1 to 600, was thoroughly infiltrated into the stump of the 
broad ligaments after they were sutured. 

Her pulse at the close of the operation was 72. She began taking 
fluid immediately after operation. The anesthesia was ideal in 
every respect. 

MISCELLANEOUS OPERATIONS. 

Atresia of the Hymen.—Atresia of the hymen and other mal¬ 
formations in this region may quite obviously be operated upon 
under simple infiltration block of the pudic nerves. (See page 350.) 


358 


SURGERY OF THE GENITO-URINARY SYSTEM 


Report of Case No. 10917. 

F. W., female, aged fifty-eight years, married, entered the hospital 
July 2, 1917. 

Diagnosis: Atresia of hymen. 

Anesthesia: Local infiltration. 

Operation: Dilatation. 

History: The patient had been married two weeks. Examination 
showed the hymen to be greatly thickened. It was impossible to 
introduce the index finger. She presented herself because of this 
condition, having just embraced matrimony. 

Technic of Anesthesia: Classical infiltration was made similar to 
that described on page 350, Fig. 144. 

A small rectal dilator was introduced and the vaginal entrance 
gradually dilated. Stellate incisions were made in the hymen until 
three fingers could be introduced into the vagina. 

The anesthesia was perfect and the patient remained in the 
hospital but two days. 

Artificial Vagina.—As an illustration of the application of local 
anesthesia to intra-abdominal, intestinal and vaginal operations the 
establishment of an artificial vagina will serve. The author’s 
experience in this class of cases is limited and yet the successful 
application of local anesthesia when meeting the demands of these 
operations has been most gratifying. 

As an example of this distressing condition and an operation which 
is somewhat unusual, but which was carried through by means of 
local anesthesia with entire satisfaction, the following case may be 
recited: 

Report of Case No. 10871. 

Miss A. S. C., aged nineteen years, entered hospital June 12, 1917. 

Diagnosis: Congenital absence of vagina. 

Operation: Procedure of Baldwin. 

First Operation: Pelvic laparotomy, intestinal loop exclusion. 

Anesthesia: Local infiltration anesthesia, 120 cc of a 0.5 per cent 
novocain-adrenalin solution and sacral anesthesia 90 cc were used. 
A midline infiltration and incision were made with the patient in 
Trendelenburg position and knees widely separated on kneeholders 
(see Fig. 141, page 346). The ovaries and tubes were found to be 
apparently normal. The uterus was absent, but a suggestion of it 
remained between the mesial extremities of the round ligaments. 
The round and broad ligaments were infiltrated, a loop of small 
bowel resected, leaving its mesentery intact, and a lateral anas¬ 
tomosis made between the divided ends. The assistant sitting: 
between the patient’s knees introduced sharp pointed scissors into 


MISCELLANEOUS OPERATIONS 


359 


the incomplete vagina from below, gently spreading the blades 
between the rectal and bladder walls. An incision was then made 
through the peritoneum between the ends of the round ligaments 
and the channel completed from above. The purse-string sutures 
at the ends of the excluded intestine which had been left long were 
grasped by a dressing forceps passed up from below and by this 
means the bowel was drawn into position thus forming a lining for 
the newly made vagina. The abdomen was closed without drain¬ 
age and the patient made a good recovery. 

The blades of a long dressing forceps were then introduced and 
clamped upon the apposing surfaces of the transplanted loop of 
intestine and allowed to necrose their way through. The lower 
ends of the transplanted intestine retracted considerably during 
the next two weeks, leaving approximately 5 cm. of the newly 
formed vagina denuded of mucous membrane. 



Fig. 149.— Artificial vagina. Roentgenogram of Case No. 10871. Vagina outlined 

by a condom distended with barium. 


Second Operation: Plastic repair. Accordingly six weeks later, 
under sacral anesthesia, a plastic operation was made employing 
the labia, which were fortunately extremely pendulous. The mesial 
half of each labium majora after being dissected free from the outer 
portion was sutured to the lower end of the retracted intestine after 
making a wide dilatation of the vagina which showed a marked 
tendency to contract. These tissues healed kindly into place and 




360 


SURGERY OF THE GENITO-URINARY SYSTEM 


the young woman has since married and has for several years enjoyed 
normal intercourse and has succeeded in keeping her husband in 
blissful ignorance of the true condition. Fig. 149 shows a roentgeno¬ 
gram which was taken of a condom distended with barium and placed 
in the vagina. 

Pelvic Abscess in Women.—The drainage of pelvic abscesses 
may be carried out under sacral, trans-sacral or parasacral anesthesia 
or under a direct infiltration of the posterior vaginal fornix (pages 
117 and 353). 

The psychic aspect of these cases is important and must be kept 
constantly in mind. The individual who is afflicted with profound 
sepsis may object to the use of local anesthesia and suffer, as 
indeed all septic cases may, from severe psychic disturbances. 
The percentage of cases so reacting is comparatively small. Thus 
one should not insist too strongly upon the use of local anes¬ 
thesia in these individuals. A light nitrous-oxide oxygen anesthesia 
will allow the introduction of vaginal pelvic drainage with great 
facility and has the further advantage of allowing one to break down 
and make multiple abscesses confluent. 

The training of patients will have much to do with their psychic 
reaction and this point is especially noticeable in relation to this 
class. 

In the author’s experience it is not uncommon to carry out these 
procedures under local anesthesia as described in cases No. 15470 
and 13633. 

Report of Case No. 15470. 

Miss L. H. N., aged twenty years, single, entered the hospital 
February 20, 1922. 

Diagnosis: Pelvic abscess of specific origin. 

Operation: Postcervical drainage. 

Anesthesia: Local infiltration. 

History: Patient had been ill for eight weeks. 

First Operation: February 21, 1922. Pelvic drainage through 
vagina. 

Technic of Anesthesia: The infiltration was made along the labia, 
retractors were inserted, the cervix was grasped with a tenaculum 
and liberal infiltration was made posterior to the cervix. This was 
followed by an incision, long curved scissors being introduced into 
the abscess and spread. x4 large amount of pus was evacuated and 
tube drainage established. 

Note.— This young woman went through the operation without 
much distress either physical or mental and one month later under¬ 
went a pelvic laparotomy under infiltration of the abdominal wall, 
combined with anterior splanchnic anesthesia, at which time the 


MISCELLANEOUS OPERATIONS 


361 


uterus, Fallopian tubes, a left ovarian abscess and a right ovarian 
cyst were removed with very satisfactory anesthesia. The technic 
used was practically the same as that of Case No. 13587 (page 501). 
Suprapubic as well as vaginal postoperative drainage was established, 
the latter following the method described on page 507. 

The drainage of pelvic abscess under sacral anesthesia is well 
illustrated by the following case: 


Report of Case No. 13633. 

D. S. R., female, aged twenty-three years, entered the hospital 
on February 7, 1920. 

Diagnosis: Pelvic abscess of specific origin. 

Operation: Vaginal drainage. 

Technic of Anesthesia: Sacral anesthesia, 90 cc of a 0.5 of 1 per 
cent novocain-adrenalin solution being introduced into the sacral 
canal. 

In about fifteen minutes the vaginal canal was easily dilated by 
the use of specuhe and the cervix was grasped with the tenaculum 
without the patient experiencing pain. An incision was then made 
in the posterior vaginal fornix and a large pelvic abscess opened 
and drained, also without pain. 


CHAPTER XII. 


LOCAL ANESTHESIA IN SURGERY OF THE 
RECTUM ANI) ANUS. 

SURGERY OF THE RECTUM AND ANUS. 

Many rectal conditions which call for surgical treatment are 
comparatively of a minor nature, and the simplicity, comfort and 
safety offered by the use of local anesthesia must, if realized, induce 
individuals with these afflictions to present themselves with less 
reluctance; and, therefore, at an earlier period than when the 
procedure is made to seem a major one by the use of general anes¬ 
thesia. 

Preparation of the Patient.—In rectal operations preoperative 
treatment is simplified as much as possible. Laxatives are avoided 
and the rectum is evacuated before operation by the administration 
of a warm suds enema. The application of irritating antiseptics 
is also avoided. Comfort upon the operating table is insured. 
Excellent exposure of the parts is insisted upon but the most scrupu¬ 
lous care should be taken to avoid unnecessary exposure of the 
patients. Intelligent male patients may be allowed to retract the 
external genitals with one hand encased in a sterile towel. 

Choice of Local Anesthetic Methods.—For all operations on the 
lower rectum and anus a direct circumferential infiltration or 
sacral anesthesia may be used. Sacral anesthesia is preferred 
only in cases in which direct infiltration is interfered with by local 
disease, such as abscesses, fistulae and cancer. Direct infiltration 
has several points of advantage. The position of the patient 
remains the same during the establishment of anesthesia and the 
performance of the operation. There is almost no margin of 
error as far as obtaining anesthesia is concerned and the time 
required for the establishment of anesthesia is less than five minutes. 
The induction of anesthesia is almost painless. 

Sacral anesthesia (Fig. 28, page 117), on the other hand, generally 
demands a change in position after the anesthetic has been intro¬ 
duced. It has a certain percentage of error. It may be impossible 
to enter the canal, needles may be broken off and toxic symptoms 
are more common under this form of anesthesia. The establish¬ 
ment of sacral anesthesia requires much more time than does 
simple infiltration and also demands a higher degree of skill and 
more training. It cannot always be established without pain. 


SURGERY OF THE RECTUM AND ANUS 


363 


Parasacral anesthesia (page 117) is still more difficult of accom¬ 
plishment. 

lrans-sacral anesthesia (page 117) is not required for the more 
simple rectal operations and its use may be reserved for operations 
upon growths higher up in the bowel. 

The Nerve Supply of This Region.—The skin of the anorectal 
region is supplied by cutaneous filaments of the fourth sacral, 
the anococcygeal nerves and by perineal branches of n. pudendus 
and n. posterior cutaneus femoris. (Fig. 138, page 348.) The 
sphincter ani externus is supplied by branches of the inferior 
hemorrhoidal branch of n. pudendus (III. IV. and sometimes 
II. S.) and by muscular branches of the fourth sacral as well 
as by sympathetics of the middle hemorrhoidal plexus. The 
internal sphincter is entirely involuntary and supplied by the 
sympathetics. The rectum is supplied by visceral branches of 
II. III. IV. S., which are motor and innervate the longitudinal 
fibers and inhibit the circular. The sympathetics on the other 
hand stimulate the circular and inhibit the longitudinal fibers. 
The “ defecation center” is independent of the brain, being located 
in the lumbar region of the spinal medulla governing the sphincters 
and muscle fibers of the rectum and anus. 

The nerves supplying the anus are the nerves that come out of 
the sacral foramina and supply the rectosigmoid region and include 
from the second to the last sacral. (Plate XIV.) 

Technic for Circumferential Infiltration.—The injection is begun 
by making a small skin wheal 2 or 3 cm. from the anal margin 
(Fig. 150). All subsequent wheals are made from beneath by the 
method illustrated in Fig. 31, page 149. In order to carry out 
this portion of the technic, intelligent assistance is required. The 
anus, located as it is in a sulcus, presents more difficulty than does 
the ordinary flat or gently rounded surface, as presented, for 
instance, by the abdominal wall. It is well to make the initial 
wheal at a point lateral to and midway between the anterior and 
posterior anal margins. From here the needle point may be 
carried along under the skin close to the anal margin until it reaches 
the median raphe, either anteriorly or posteriorly, where a secondary 
wheal may be developed. The subdermal infiltration between 
the initial wheal and the secondary wheal may accompany either 
the advance or retreat of the needle point and the surgeon may 
note the elevation of the skin as the fluid is introduced. The 
needle may now be introduced through the initial wheal and carried 
to the opposite pole of the anal margin, where the above procedure 
is duplicated. In this manner one-half of the anal margin is anes¬ 
thetized and wheals are thus produced at the central points in 
front of and behind the anus. The needle point may now be 


3G4 LOCAL ANESTHESIA IN SURGERY OF RECTUM AND ANUS 


introduced through the first secondary wheal at the midline (gen¬ 
erally the anterior wheal is found most convenient) and from here 
the needle may be carried subdermally to a point opposite the 
location of the initial wheal, where another skin wheal is made, 
and this quadrant of skin anesthetized. Through this wheal the 
needle may be inserted and may be conveniently carried across 
the remaining quadrant which leads to the sulcus between the 



Fig. 150.—Surgery of the rectum and anus. Anesthesia technic: subdermal 

circumferential infiltration. 


gluteal folds behind the anus. Gentle retraction of the skin by 
the assistant will serve to straighten out the lines along which the 
needle point is to travel and greatly facilitate the working out of 
this part of the infiltration. Flexibility of the needle also facilitates 
the carrying out of this procedure. 

A circular ring of anesthesia just external to the anal border is 
thus established. Through this anesthetized skin the needle may 
be introduced in a plane at right angles to the skin surface and 



SURGERY OF THE RECTUM AND ANUS 


365 


parallel to the wall of the rectum. The use of a fine needle 7 to 
10 cm. long is desirable. (Figs. 2, 3, 4, pages 87 and 88.) One 
should aim to establish a wall of infiltration about the rectal canal. 
1 he infiltration should be most complete in the posterior lateral 
areas, but little being required in the anterior quadrant. In making 
this infiltration it is essential to observe the rule that the needle 
point be kept constantly in motion while the fluid is emerging from 



Fig. 151.—Surgery of the rectum and anus. Anesthesia technic: perirectal infil¬ 
tration; fenestrated speculum in use (Fig. 25, page 109). Insert shows sectional 
view. 


it. The presence of large vessels in this region is a constant source 
of danger unless this rule be rigidly observed. As soon as the 
rectum has been surrounded by a wall of infiltration to a depth 
of 5 to 8 cm. one may conveniently, and without distress to the 
patient, introduce the fenestrated speculum (Fig. 25, page 109 
and Fig. 151) and spread its blades to a degree which will allow 
one to visualize the rectal mucosa. If sensation still remains the 





360 LOCAL ANESTHESIA IN SURGERY OF RECTUM AND ANUS 


anesthetic may now be conveniently reinforced by a submucous 
infiltration made directly under the vision. 

V 

The presence of abscesses or suspected malignant disease pro¬ 
hibits the use of the above technic and either an infiltration block 
at a greater distance from the rectal wall should be made or sacral 
anesthesia should be resorted to in these cases. 



Fig. 152.— Surgery of the rectum and anus. Anesthesia technic. Photograph 
of divulsion of the sphincter; Pratt’s dilator (Fig. 24, page 109) and Sims’s speculum 
in action. 


Sphincter Divulsion.— In the simple cases divulsion of the 
sphincter may now be accomplished, and in its accomplishment 
bilateral, symmetrical, stealthy, gradual stretching should be rigidly 
observed. For this some form of mechanical device (Fig. 24, page 
109) should have precedence over the fingers or thumbs. The 
blades of the dilator shown in the figure may be spread gradually 





SURGERY OF THE RECTUM AND ANUS 


367 


as the muscle relaxes under the effects of the anesthetic, without 
being subjected to an intermittent strain, or what might be called 
repeated insults, each of which has the effect of stimulating in 
the muscles, a reflex contraction. In making the divulsion, when 
the lateral limits have been reached and a greater dilatation seems 
desirable a Sims s speculum may be used for the purpose of making 



Fig. 153. —Surgery of the rectum and anus. Anesthesia technic. Photograph of 
patient with divulsion of the sphincter completed. 


a gradual pull in the anterior direction. (Fig. 151 and 152.) In 
order to facilitate this stage of the procedure the gloved hand may 
be introduced with the back upward between the blades of the 
dilator and the dilatation increased by forcing the dilator back¬ 
ward and the Sims’s speculum forward. The establishment of 
perfect local anesthesia in rectal cases by abolishing the reflexes 
renders divulsion of the sphincter much more simple as a rule than 





368 LOCAL ANESTHESIA IN SURGERY OF RECTUM AND ANUS 


when general anesthesia is used. As soon as complete divulsion 
has been accomplished the necessary operation may, of course, be 
carried out. Fig. 154, A, B, and C, represent steps of the hemor¬ 
rhoid operation by the clamp and cautery method. 



Fig. 154.—Hemorrhoidectomy. Clamp and cautery method. A, B and C, 

representing various steps of operation. 


Rectal Examination.— While many rectal examinations may be 
made without the use of anesthesia, a certain percentage of 
individuals suffer exquisitely from the introduction of instruments 
into the rectum. The tenesmus exhibited by the sphincter which 
has undergone long periods of irritation from disease makes the 
introduction of instruments difficult and painful. It would seem 
advisable to refrain from making rectal examinations in a certain 
percentage of these cases until anesthesia had been established. 
The same rule as that used for cystoscopy might be applied. The 
author has made it a practice for a number of years to refrain from 
making rectal examinations in cases in which it was more or less 
obvious that an operation was necessary until after anesthesia 
had been established; and even where the necessity for an operation 
seemed probable and an attempt at examination proved painful, 
lie has, without hesitation, anesthetized the region in order to 












SURGERY OF THE RECTUM AND ANUS 


369 


make the examination more complete and, at the same time, pain¬ 
less. 


Hemorrhoids, Ulcers, Fissures and Polypi,— Anesthesia for the 
operation for hemorrhoids may be established by the use of the 
circumferential infiltration, described on page 363, or by the use 
of sacral anesthesia. Infiltration block combined with direct 
infiltration is the method of choice. The technic described 


on 


page 149 is carried out with the utmost attention to detail, every 
effort being made to avoid causing the patient pain while the 
injection is in progress. The sphincter is divulsed by the use of the 
Pratt speculum (Fig. 24, page 109), and one should not be unduly 
hasty in carrying out this procedure. Deliberation is essential 
to success at this stage of the operation. Any method one chooses 
may be used in the treatment of the condition as the anesthesia, 
if carefully established, admits of no margin of error. It is the 
author’s rule to complete the operation wherever possible without 
the patient’s knowledge; that is, the patient is made to believe 
that he is being prepared for the operation, and not infrequently 
w r e are able to complete every detail before informing him. This 
method is especially desirable in patients who are at all appre¬ 
hensive. 

Excisions of ulcers, fissures and polpi may be carried out under 
the same method as that described for the hemorrhoid operation. 

Fistula-in-Ano.— Local anesthesia for the treatment of fistula-in- 
ano may be established by means of a direct circumferential infil¬ 
tration, direct infiltration or sacral anesthesia. As a rule, it has 
been found w r ell to avoid the use of direct infiltration in these cases 
and to give preference to an infiltration block at some distance 
from the field of operation. Sacral anesthesia is perhaps the 
method of choice, but in its use one should be especially careful to 
avoid carrying infection into the sacral canal. The establish¬ 
ment of sacral anesthesia will permit of the most extensive dis¬ 
section in this region and its use in the treatment of this condition 
is highly satisfactory. 

The divulsion of the rectal sphincter as a preliminary is of decided 
advantage in making the dissection. Excellent light, a com¬ 
fortable position on the table and good retraction are also desir¬ 
able adjuncts. One of the advantages of anesthesia by infiltration 
when operating for fistula is offered by the hemostatic effect of 
the adrenalin. Both infiltration block and sacral anesthesia offer 
to the surgeon the opportunity of operating upon a silent field, 
which is so much to be desired in procedures of this kind which 
may in some instances present more or less technical difficulty. 

While, theoretically, sacral anesthesia would seem most desir¬ 
able in cases of fistula-in-ano and ischiorectal abscess, direct infil- 


34 


370 LOCAL ANESTHESIA IN SURGERY OF RECTUM AND ANUS 


tration has been found to be quite satisfactory. Sacral anesthesia 
involves the possibility of carrying infection into the sacral canal 
provided the infective processes for which the patient is being 
treated approach the area through which the needle is to be inserted. 
In all cases the element of infection must be considered. How¬ 
ever, the objection to infiltration anesthesia in these cases, which 
relates to the possible spread of the infective organisms by means 
of the infiltrating needle, is believed to be more theoretical than 



Fig. 155.—Fistula-in-ano. Anesthesia technic; subdermal circumferential infiltra¬ 
tion and deep infiltration block. 


real. Considerable experience in circumferential infiltration in 
complicated cases of fistula-in-ano and direct infiltration for the 
purpose of draining ischiorectal abscesses have failed to show any 
practical objection to this method. There are in this region no 
tissues which can be injured by direct infiltration. In these con¬ 
ditions the opportunity offered for painstaking, careful dissection 
and the bloodless and silent field are much to be desired. 

Infiltration Block.—In making an infiltration block for the dis¬ 

section of fistula-in-ano one should make the injection at a dis- 





SURGERY OF THE RECTUM AND ANUS 


371 



Fig. 156.—Fistula-in-ano. Dissection of tract. 



Fig, 157,—Fistula-in-ano, Photograph of Case No, 11775, during operation 













372 LOCAL ANESTHESIA IN SURGERY OF RECTUM AND ANUS 


tance as great as possible from the fistulous tracts. A subdermal 
rhomboid is made at a distance of 2 to 3 cm. from the fistulous 
tract and extending about the anus (Fig. 155). Through this 
anesthetized area of skin the needle is introduced vertically, begin¬ 
ning preferably posteriorly and interrupting the nerves of the 
region as near their point of exit as possible. The deep infiltra¬ 
tion should, as a rule, extend completely about the rectum. This 
tissue presents no structures which may be damaged by the needle. 
After complete divulsion of the sphincter the author has as a rule 
injected a solution of methylene blue into the fistulous tract for 
the purpose of making identification of the tissues more easy. A 
simple expedient is the introduction of a flexible silver wire through 
the fistulous tract before beginning the dissection. The tract and 
wire may then be completely dissected out, thus reducing the margin 
of error which is always present to obstruct our efforts at complete 
ablation of the pathological process (Fig. 156). 

Fig. 157 shows a photograph of Case No. 11775 undergoing an 
operation for this condition and the following case illustrates the 
various steps carried out in the operating room. 

This case will illustrate the application of infiltration block in 
the treatment of fistula-in-ano of an extensive degree: 


Report of Case No. 9331. 

G. C. S., aged fifty-six years, entered the hospital on October 10, 
1916. He weighed 140 kilograms and presented multiple fistuke 
with four skin openings about the anal region. 

Diagnosis: Fistula-in-ano (multiple). 

Operation: Excision of the fistulous tracts, October 14, 1916. 

Anesthesia: Circumferential infiltration block. 

A circumferential infiltration block, using 210 cc of a 0.5 of 1 
per cent novocain-adrenalin solution, was made surrounding the 
rectum and extending external to the most distant opening, which 
was located 17 cm. from the anal margin on the left of the buttock. 
Methylene blue solution was injected into the tracts after thoroughly 
divulsing the sphincter. The fistulous tracts were completely dis¬ 
sected out and the wound packed widely open. No sutures were 
placed. A complete infiltration block with quinine and urea hydro¬ 
chloride, 1 to 600, was used. The patient had no pain after the 
operation and postoperatively there was great difficulty in keep¬ 
ing the skin edges separated on account of the extreme adiposity 
of the patient. At one point, during the absence of the author 
from the city, the skin healed across, giving a channel beneath it. 
Upon his return a sound was passed through this channel and the 
skin once more divided without the use of anesthesia and without 


SURGERY OF THE RECTUM AND ANUS 


373 


sensation to the patient. Our records show that this incision was 
made seventeen days after the operation, the anesthesia still remain¬ 
ing was assumed to be from the use of quinine and urea. 

Note .—This patient had no reaction following his operation and 
the incision and tissues remained healthy throughout. This case 
serves to illustrate very well the aid that may be derived from 
the use of quinine and urea hydrochloride, besides the extent to 
which dissections of this nature may be carried out under an infil¬ 
tration block. 

Carcinoma of the Rectum.— Malignant disease of the rectum 
makes a great demand upon local anesthesia for two reasons. First, 
if limited in extent the excision of malignant growths becomes as 
simple under the local method as are any of the other operations 
which it may be necessary to perform in this region. Secondly, 
the average case of cancer of the rectum demanding wide resection 
is always a desirable candidate for local anesthesia on account of 
the additional safety offered by this method. 

The condition of these patients and the mortality resulting 
from cancer of the rectum would seem to demand the additional 
safeguard offered by local anesthesia. 

Several methods are available: (1) Growths appearing low in 
the rectum may be removed after the establishment of an infil¬ 


tration block, made well away from the area involved; (2) sacral 
anesthesia (page 117) may be employed, or (3) parasacral anes¬ 
thesia may be established by the anterior approach of Braun 
(page 117). 

Growths higher up in the rectum, which demand the Kraske 
operation, for instance, may be removed absolutely without pain 
following the method of trans-sacral blocking, described on page 
117. The establishment of this anesthesia, while slightly more 
irksome than others, will, if combined with a paravertebral block, 
give an anesthesia as high as desired and, as stated above, has 
advantages which are well worth the additional effort. 

Prolapse of the Rectum. —Rectal prolapse of a mild degree which 
will respond to treatment by linear cauterization may be treated 
under a circumferential infiltration block about the rectal canal. 
However, many of these patients require, in addition, an intra- 
peritoneal operation. The following technic is especially satis¬ 
factory in this class. Sacral anesthesia (page 117) is established. 
A linear cauterization of the protruding rectal mucosa is first 
made. The picking up of the rectal mucosa by means of artery 
forceps is greatly facilitated by the cooperation of the patient who, 
by straining, may cause the rectal mucosa to evert to any desired 
degree. (Fig. 158.) In cases in which the rectal mucosa recedes 
automatically with the patient in the recumbent posture the aid 


374 LOCAL ANESTHESIA IN SURGERY OF RECTUM AND ANUS 


offered by the patient’s cooperation is most desirable. The patient 
should be instructed to force the rectal wall outward by straining 
and when the limit is reached one may pick up the mucous membrane 
at the desired points, the amount of bowel wall which is extruded 
under these conditions being an excellent indication to the surgeon 
of the length of the lines which are to be cauterized. Following 
the cauterization, the abdominal wall may be infiltrated with the 
patient in the exaggerated Trendelenburg position and tilted well 
to the right. A left rectus incision is made, carefully observing 
the precautions laid down in Chapter XVIII, page 489, every effort 
being made to obtain a negative pressure when the abdomen is 
opened. Provided the pelvis is free of small intestine, an anterior 



Fig. 158.—Prolapse of the rectum. (Codperation of patient.) Photograph of Case 

No. 14259. Voluntary extrusion of mucosa. 

splanchnic anesthesia is at once established and the mesosigmoid 
thoroughly infiltrated with novocain solution. The operation 
which the author has performed for this condition has been to 
displace the rectosigmoid to a position behind the posterior parietal 
peritoneum. It is, therefore, essential to anesthetize the parietal 
peritoneum not only along the pelvic brim but along the posterior 
abdominal wall to the left. The height to which the anesthesia 
is carried will depend upon the redundancy of the rectosigmoid. 
With this anesthesia practically any procedure which one chooses 
may be carried out. 

As examples of the above the following Case Reports Nos. 11401 
and 14259 are offered: 




SURGERY OF THE RECTUM AND ANUS 


375 


Report of Case No. 11461. 

This case well illustrates the simplicity with which simple rectal 
prolapse of mild degree may be treated under local anesthesia: 

J. L. H., aged sixty years, entered the hospital April 12, 1918. 

Diagnosis: Rectal prolapse. 

Operation: Linear cauterization. 

Technic of Anesthesia: Circumferential infiltration. Ninety cc of 
a 0.5 of 1 per cent novocain-adrenalin solution were introduced, 
making a wide infiltration block about the rectum. The patient was 
instructed to strain and force the mucous membrane out. Several 
artery forceps were then placed upon the rectal wall and linear 
cauterizations made. The skin about the rectum was punctured 
at several points and 60 cc of 1 to 600 quinine and urea hydrochloride 
were used as an infiltration block for the purpose of preventing 
postoperative pain. 



Fig. 159.—Prolapse of the rectum. Photograph of Case No. 14259. Mucous 
membrane grasped, ready for linear cauterization. 


Report of Case No. 14259. 

Mrs. J. II., aged fifty-two years, entered hospital May 9, 1921. 
Diagnosis: Prolapse of rectum. 

Operation: Linear cauterization of rectum and abdominal recto¬ 
pexy. 











376 LOCAL ANESTHESIA IN SURGERY OF RECTUM AND ANUS 


History: Aggravated constipation for a number of years. Has 
been bleeding from bowel three years. Bowel protrudes with 
each bowel movement. 

Anesthesia: Local infiltration for the abdominal wall using 90 cc 


of a 1 per cent novocain-adrenalin solution and sacral anesthesia 
using 60 cc of a 1 per cent novocain-adrenalin solution. Multiple 
linear cauterization was done without divulsing the sphincter. The 
cooperation of the patient made it possible to obtain the exposure 
shown in Fig. 159 and the cauterization was carried out before open¬ 
ing the abdomen. The abdomen was opened by a left rectus incision 
under infiltration anesthesia with the patient in an exaggerated 
Trendelenburg position. A perfect negative pressure resulted 
and a modified Moscowitz operation was carried out, throwing 
the rectosigmoid behind the posterior parietal peritoneum. 

The following case will serve to illustrate the carrying out of 
the operation for rectal prolapse when associated with disease of 
the adnexa, necessitating other pelvic work. 


Report of Case No. 13561. 

C. G. M., aged fifty-two years, entered hospital January 23, 1920. 

Diagnosis: Moderate-sized uterine fibroids; prolapse of the 
rectum (marked degree), kyphosis, pelvic deformity. 

Operation: Myomectomy; uterine suspension; rectopexy; linear 
cauterization. 

Anesthesia: Local infiltration; anterior splanchnic. 

The abdomen was opened after a midline infiltration, using 90 
cc of a 0.7 of 1 per cent novocain-adrenalin solution. Although a 
negative intra-abdominal pressure was obtained the conformation 
of the patient’s body was such that the small intestine, a part of 
the stomach and practically the whole of the colon lay below the 
pelvic brim. The patient presented a marked kyphosis with almost 
an obliteration of the upper abdominal cavity. Therefore a rubber 
towel was placed above the incision and the whole mass of small 
intestine and the transverse colon were turned out upon this towel, 
where they were retained by the use of warm pads throughout the 
operation. 

The uterine fibroid proved to be intraligamentous. An anterior 
splanchnic anesthesia was established, the round ligaments were 
blocked and the fibroid, which was the size of a large orange, was 
removed. The round ligaments were shortened and a rectopexy 
was performed by mobilizing the pelvic colon and placing it in a 
retroperitoneal position. 

The anesthesia is recorded as ideal in this case, the intestines 
being eviscerated and returned to the abdominal cavity without 


SURGERY OF THE RECTUM AND ANUS 


377 


sufficient distress to cause the patient to complain. Traction, 
however, was carefully avoided and the patient showed no signs of 
distress when the intestines were returned to the abdomen. 

Second Operation: Twelve days after the performance of this 
operation a circumferential infiltration was made about the anal 
canal and the sphincter divulsed. Four linear cauterizations of 
the rectal mucous membrane were made. The patient made an 
uneventful recovery. 

Note .—This case, complicated as it was by the presence of a 
subperitoneal uterine fibroid growing directly out from the cervix, 
and a deformed pelvis and spine which caused practically an oblit¬ 
eration of the upper abdominal cavity, presented complications 
which offered a prospect of considerable difficulty in completing 
surgical treatment under straight local anesthesia. However, 
the combination of sacral anesthesia, a moist rubber towel, eviscer¬ 
ation of the small intestine and anterior splanchnic anesthesia 
made this operation practically as simple as was the operation of 
Case No. 14259, reported above. 

Postoperative Comfort. — Quinin and Urea Hydrochloride.— In all 

granulating wounds in this region, aside from those which result 
from the excision of malignant disease, quinin and urea hydro¬ 
chloride, 1 to 600, may be used with advantage for the purpose of 
reducing postoperative discomfort. The author has seen anesthesia 
following the use of this drug last for seventeen days (Case No. 
9331),although, as a rule, the anesthesia does not last more than 
twenty-four or forty-eight hours, and its action is by no means 
constant. 





PART III. 


LOCAL ANESTHESIA IN SURGERY OF THE 
ABDOMINAL WALL AND CAVITY. 


CHAPTER XIII. 


LOCAL ANESTHESIA IN SURGERY OF THE ABDOMEN. 


GENERAL CONSIDERATIONS. 


1. The nerves of the abdominal wall and the peritoneum (Fig. 160. 
See Plates IX and X). 

The skin of the abdominal wall is supplied by the: (1) Thoracico- 
abdominal intercostal nerves (MI. VIII. IX. X. XI. T.) which give 
oil' anterior and lateral cutaneous branches; (2) the twelfth thoracic 
nerve; and (3) ramus cutaneous anterior or the hypogastric branch 
of the iliohypogastric nerve (I. L.), which supplies the skin of the 
hypogastric region. 

The muscles and fascia are supplied by practically the same 
nerves, the anterior cutaneous branches of the thoracico-abdominal 
nerves giving off muscular branches to the recti muscles, and the 
lateral cutaneous branches of the same nerves giving muscular 
branches to the external oblique muscles of the abdomen. 

The peritoneum, as has been shown by Kappis and others, 
receives its nerve supply from the sympathetics. 

Intraperitoneal Pain Sense.— Much has been written about 
the pain sense of the different intraperitoneal structures. Few 
authorities agree upon this important subject, each giving the 
results of his own studies and observations. Careful study has 
been made of the works of Hertzler, Lemander, Haller, Bichat, 
Weber, Bloch, Richet, Kast and Meltzer, Ritter, Wilms, Propping, 
Ramstrom, Langley, Bayliss and Starling, Cannon, Auer, Kuntz 
and Mackenzie, and in addition, a large series of the author’s own 
cases were carefully observed in order to clear up, if possible, 
some of the disputed points. Going over the literature will 
show one the marked contrast in the reports of the different 


380 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN 


observers, and, aside from theoretical or anatomical grounds upon 
which arguments are based, one is convinced that much of the 
difference of opinion is due to the fact that the findings are far 
from constant in different individuals and vary even under similar 
conditions and greatly under a variety of conditions. The various 
stages of peritonitis from different causes greatly influence the 



Fig. 160.—Nerve supply of the abdominal wall. 1, costa XII; 2, N. intercostalis 
XII; 3, rami musculares; 4, M. transversus abdominis; 5, N. iliohypogastricus; 6, 
ramus musculares; 7, ramus cutaneus lateralis, N. iliohypogastricus; 8, N. ilio- 
inguinalis; 9, rami cutanei anteriores, N. intercostalis VIII; 10, sheath M., rectus 
abdominis; 11, M. obliquus interims abdominis; 12, rami cutanei anteriores, N. inter¬ 
costalis XII; 13, funiculus spermaticus. 


sensitiveness of the parietal peritoneum and the viscera. The 
general condition of the patient must be taken into account and 
it must not be forgotten that the patient who has been a sufferer 
with a painful retroversion or recurrent interval appendicitis may 
respond differently than will an individual who is the subject of 
some other pathological condition. It is generally taught that the 
parietal peritoneum only is sensitive and that the viscera are 




GENERAL CONSIDERATIONS 


381 


devoid of pain sense in the absence of traction upon the mesentery, 
the author’s observation indicates that this is not entirely true, 
draction upon the intestine even without traction upon the mesen¬ 
tery may cause pain; heat applied to the exposed intestine will 
produce cramps which are described as gas pains. A young man 
of excellent poise and intelligence stated that the introduction of 
the needle through the wall of his intestine was painful, and a 
careful test showed that he could feel the needle pass through 
his intestinal W T all even though his eyes were covered and an effort 
made to deceive him. Traction upon the mesentery w r as here 
carefully excluded. The parietal peritoneum in the absence of 
inflammation is insensitive to light touch or even to scratching. 
However, pinching and traction are disagreeable. In disease this 
structure is sensitive even to light pressure. This is especially 
true of certain areas as, for instance, the cul-de-sac. The results 
of observation will also vary with the manner in which experi¬ 
ments are made. A brisk, quick action w ill cause complaint when 
the same act stealthily performed may be readily tolerated. One 
observer states that the mesoappendix may be clamped without 
pain and backs up his opinion by observations upon a series of 
fiftv cases, while another finds that this structure is always sensitive, 
especially in acute appendicitis. The facts are that the sharp 
application of a hemostat to the mesoappendix will elicit a com¬ 
plaint from the conscious patient who has not had preliminary 
medication unless cocain has been used. (Some authors state 
that cocain acts as a general analgesic but I have had no experience 
with it.) However, if one slowly and carefully applies the clamps 
the patient may not remonstrate. Many factors must be con¬ 
sidered in making this simple observation. Whereas, as a rule, 
the patient w ho is undergoing an operation under local anesthesia 
is ready to complain at the slightest opportunity, and may even 
complain when not being hurt, with the hope of making the surgeon 
more cautious, one must not forget that he may have been compelled 
to suffer so much during the delivery of the appendix that by com¬ 
parison the clamping of the mesoappendix may not bring forth a 
complaint. In no other manner can an observation of this kind, 
which is so at variance with the author’s ow r n experience, be 


explained. 

Thus it has been frequently found that a strong clamp may be 
placed upon the mesoappendix, provided it is forced down very 
slowly, with only slight complaint on the part of the patient. It 
is known that the base of the appendix may be clamped with no 
pain sense after the mesoappendix has been blocked or divided. 
The ovarian pedicle, the cystic duct, and even the fundus of the 
uterus are tender and cannot be attacked without causing pain, 


LOCAL ANESTHESIA IN SURGERY OF ABDOMEN 


QQO 

ooZ 

although the latter may be found to be almost insensitive in some 
cases. The large vessels in the mesentery are sensitive and even 
those in the omentum, if clamped close to their origin, may show 
pain sense. There is, therefore, an opportunity to perform opera¬ 
tions upon most of the pelvic viscera when the above-mentioned 
areas can be blocked before the operative procedure is begun. 
Pathological conditions which cannot be handled without traction 
upon the mesentery, mesoappendix or posterior abdominal wall 
may not lend themselves to this form of anesthesia. However, 
here again is a good illustration of the difference between careful 
and rough handling of the tissues. A perfect exposure with a 
perfect negative pressure may and often does give one the oppor¬ 
tunity to see the retaining bands which anchor the tissues to the 
posterior abdominal wall with the aid of only slight traction while 
the bands are cut with scalpel or scissors and the parts liberated. 
A good exposure will give one the opportunity of reinforcing the 
anesthesia. When the necessity for traction can be anticipated 
the tissues upon which traction is to be made should be blocked 
at their points of origin from the abdominal wall. In a number 
of instances adherent pus tubes have been removed by following 
this plan. Masses which appear to be very adherent and resistant 
will be found to shell out easilv at times after cutting the “kev” 
bands under direct vision. The important point is to locate the 
lines of cleavage with as slight an amount of traction as possible 
and to chp the retaining bands as they appear. 1 

It is interesting to note the opinion of Heinrich Braun in relation 
to the performance of laparotomies under local anesthesia. He 
states that: '‘To do laparotomies under local anesthesia with success 
depends on a series of circumstances which must be well considered 
in the individual case. It was an old experience after the discovery 
of the ether atomizer that occasionally a painless skin incision 
sufficed to open the abdomen and possibly for an operation upon 
organs which possess little or no sensation of pain. The local 
anesthesia by cocain and its substitutes has brought a substan¬ 
tial progress in so far as it was possible to get a real interruption 
of sensation with ease and sufficient safety while severing the 
abdominal layers from skin to peritoneum. 

“If the operative field lies essentially within or next to the 
abdominal wall, as in the majority of hernias, or if a simple incision 
reveals at once the organs to be operated upon, lying adjacent to 
the anterior abdominal parietes, further manipulation within the 
abdomen is unnecessary, then the anesthesia of the abdominal wall 
alone is sufficient. Incisions into the stomach and gut, the liver, 


! Braun; Local Anesthesia, p. 296, 


GENERAL CONSIDERATIONS 


OQO 

ooo 


gall-bladder and the rest of the abdominal organs are not painful. 
The behavior of these organs either in the state of inflammation 
or normal is alike. Let every pull at the intestines and every 
touch or tear on the parietal peritoneum, if not under the influence 
of the anesthetic, produces the abdominal sensations of pain, but 
quite indistinctly localized. 

“Between the aponeurosis and the peritoneum the injected 
fluid spreads quite far around so that a broad strip of peritoneum 
becomes insensible. 

“ Certain laparotomies may be done entirely with local anesthesia 
without the aid of narcotics following this simple infiltration of 
the line of incision. To these belong the gastrostomy with trans- 
rectus incision. While infiltrating the abdominal layers from 
both ends of the line of incision, one must make sure that the 
needle penetrates both rectus sheaths and reaches the preperitoneal 
tissue. That is indeed not difficult, since by the penetrating needle 
one can sense the resistance of the aponeurosis very accurately. 
We operate in like manner for tuberculous ascites and abscesses 
of the liver which are accessible from the abdomen. Also in the 
establishment of intestinal fistula? most generally the simple infil¬ 
tration suffices but in cases of ileus one must handle the needle 
with great care to avoid spearing the part of the intestine to be 
opened which lies distended and pressed against the abdominal 
wall. 

“An essentially broader field of operation inside of the abdominal 
layers is rendered insensible if the simple infiltration of the incision 
area is replaced by regional eircuminfiltration. 

“Usually, however, this is not the case. On the contrary, every 
examination of the abdominal organs—the introducing of the 
hand, the placing and removing of compresses, the loosening of 
adhesions—is so painful that further operation cannot be thought 
of. Ways and means had to be found, therefore, to meet the 
painful sensations given rise to by the organs of the abdominal 
cavity. Last, but not least, in many operations, especially in the 
lower parts of the abdomen, we cannot do without the artificial 
relaxation of the muscular layers. ” 

The author’s experience does not entirely coincide with that 
expressed above. While it is extremely desirable and indeed 
necessary to obtain relaxation of the abdominal walls in order to 
do intra-abdominal surgery there are many conditions which can 
be met under the use of this anesthesia alone by employing strategy 
and local infiltration at the proper points. 

One of the most surprising experiences was the realization of 
the extent to which abdominal explorations might be carried 
under simple infiltration of the abdominal wall. With relaxed 


384 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN 


parities, vertical retraction, combined with a negative intra-abdominal 
pressure and tilting of the table so as to make use of the force of 
gravity , one is frequently able to explore the upper abdomen through 
a pelvic incision and vice versa. (See abdominal exploration, page 
379.) 

Position of the Patient.— As stated in the chapter on General 
Technic, much may be gained by tilting the operating table so as 
to bring the body of the patient into a suitable position. For 
upper abdominal work the reversed Trendelenburg with the tilt 
to the right or left may change the position of the abdominal 



Fig. 161.—Patient draped and showing position of pneumatic injector. A, leg 
holder; B, lateral body support; B\ shoulder brace; C, operating field guarded 
by towel hooked on towel rack; D, arm supported for comfort and blood-pressure 
reading. 


organs, and likewise the aspect of the surgical problem, to a con¬ 
siderable degree. While this fact has long been recognized in rela¬ 
tion to the surgery of the pelvis, surgeons seem slow to realize how 
much may be gained by the tilting of the table when working in 
the upper abdomen. The lateral tilts (see Fig. 202, page 473), if 
made in the presence of a perfect negative intra-abdominal pressure, 
will often shift the small intestine to one side of the midline, leav¬ 
ing the ascending or descending colon, as the case may be, in the 
other half. In order to obtain these results, it is of course neces¬ 
sary to thoroughly abolish the reflexes and to tilt the patient’s 




























































































GENERAL CONSIDERATIONS 


OO 


body as a rule to an angle of about 30 degrees. Fig. 161 shows 
the patient on the table with the pneumatic padded braces in 
place for the lateral tilts and Trendelenburg position. 

Retraction. —In abdominal work good exposure is a sine qua non 
to success. It is to be hoped that the day of finger retraction is 
soon to pass. It is incompatible with asepsis and the desired 
result can be much more easily attained by the use of proper retrac¬ 
tors which will take up less room and, as a rule, do the work 
much more satisfactorily. Ilarsh retraction will produce much 
the same effect as inefficient anesthesia. Instances have occurred 
in which an otherwise ideal local anesthesia was converted into 
a failure and general anesthesia found necessary because a careless 
assistant allowed the abdominal wall to slip from a retractor, 
thus causing a contraction of the abdominal muscles and an ex¬ 
pulsive effort, resulting in the extrusion of a large mass of intestinal 
coils. The most important point about retraction, when working 
under local anesthesia, is that it be steady; that is, continuous and 
not intermittent or jerky. “Stealthy” is the word which best 
describes the manner of doing our work most satisfactorily under 
local anesthesia. Retraction should be symmetrical, if possible; 
that is, equal on the opposite sides of the wound, especially if 
continued for a long time. Forceful retraction, if made slowly, 
carefully and methodically, is not usually objected to (see pages 
98-100, Figs. 11, 12 and 13). 

Direction, Site and Choice of Incisions.— While local anesthesia 
does not contraindicate the use of any particular incision its use 
demands an adequate exposure of the pathology present, and when 
operating under its influence great advantages may be gained 
from a proper selection of the abdominal incision. In the author’s 
experience the transverse or “L” incision has given the most 
excellent exposure when working in the upper abdomen, and he 
has used it almost exclusively since 1910. With proper equip¬ 
ment one may anesthetize and enlarge any abdominal incision 
at the rate of about 2 or 3 cm. per minute. (See Case No. 15117.) 

Note.— This case illustrates the possibility of carrying the incision 
from one field to another should the necessity arise. Although 
this patient was in a grave condition at the beginning of his 
operation, his condition improved steadily throughout the pro¬ 
cedure. The incision, 30 cm. in length, was prepared by infil¬ 
tration anesthesia with a loss of time not to exceed ten minutes 
and the operation was carried out with dispatch and without 
embarrassment. Explorations of this character are almost ideal 
under the use of infiltration anesthesia. The wound may be enlarged 
to any desired extent as the necessity arises. 


25 


386 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN 


Report of Case No. 15117. 

S. B. R., aged seventeen years, entered the hospital January 
21, 1922. 

Diagnosis: Gunshot wound of abdomen. 

Operation: Laparotomy; retroperitoneal drainage. 

Anesthesia: Local infiltration 180 cc of novocain-adrenalin 
solution. 

History: Twelve hours previously patient had been struck by 
a bullet which entered the abdomen in the right loin. The roentgen 
rays showed the bullet in the left pelvic wall posteriorly, there being 
no wound of exit. The patient was given 250 cc of citrated blood 
and one liter of physiological saline intravenously. Under infil¬ 
tration anesthesia the abdomen was opened on a line extending 
diagonally from the twelfth rib behind where the bullet entered. 
The external oblique was divided in line with its fibers and the 
retroperitoneal space opened. A large amount of clotted blood 
was removed, the peritoneal cavity was then opened by extending 
the incision across the abdomen to the midline below the umbilicus. 
Considerable blood and serum escaped. The mesoappendix was 
found perforated. The intestinal tract was gone over system¬ 
atically, each loop being returned as soon as it was examined. No 
perforation was found. Drainage was inserted and the incision, 
which was 30 cm. in length, was sutured. The patient’s pulse 
remained unchanged throughout the operation. His color improved 
greatly and he was returned to bed in good condition. Recovery 
was uneventful for two weeks when he began to evidence edema 
and tenderness, first in the right leg and then in the left, accompanied 
by severe pain. The patient died on February 17, with a diagnosis 
of thrombosis of the femoral and iliac veins and of the inferior 
vena cava, which was confirmed at autopsy. 

Therefore, one should not hesitate to enlarge the incision in any 
direction when unexpected pathology is encountered or when 
other conditions arise which make this procedure seem advisable. 
The realization of the ease with which this may be done effectually 
eliminates the necessity for making the original infiltration far 
beyond the limits of the regular incision and meets the criticism 
that other pathology cannot be reached. 

The direction, site and length of the abdominal incision has 
such an intimate relation to the success or failure of local anes¬ 
thesia in abdominal surgery that the following article, 1 which 
appeared in 1919, seems apropos: 

1 Farr, Robert Emmett: The TriWH , §Qtus Ihci§ioa ij} the Upper Abdotaem 
MhwegQta Medicine, May 1919, 


GENERAL CONSIDERATIONS 


387 


The Trans-rectus Incision in the Upper Abdomen. — “The proper 
performance of an intra-abdominal operation demands an incision 
through the abdominal wall of sufficient length to allow the surgeon, 
in so far as it is possible, to do his work unhampered by the inter¬ 
ference of the abdominal parietes. During recent years long 
incisions have been made with less hesitancy and with a corre¬ 
sponding improvement in surgical therapy. Nevertheless, every 
effort should be made to conserve the abdominal parietes as far 
as may accord with the proper handling of the intra-abdominal 
problem. It may be true that under absolute asepsis rather long 
incisions heal as rapidly as do short ones, but this ideal does not 
always obtain. In any event, the conditions which tend to pro¬ 
duce incisional hernia are favored by the long scar; also, the forces 
acting are, in some degree, proportionate to the length of the scar. 
When pathological conditions demand long incisions, the injury 
to the abdominal wall becomes at once of relatively minor 
importance. Long incisions may even be indicated in order to 
arrive at a diagnosis in some cases, but too often this is evidence 
of failure on the part of the surgeon to complete his differential 
diagnosis before operation.” 

In a former contribution 1 on this subject the author stated: 

“When work in both the upper and lower abdomen is called 
for in the same patient, it may be a mistake to prolong an incision 
from one to the other field, especially the pararectal incision. 
Perhaps it is better to make a second incision in those cases. The 
slight loss of time will be compensated by decreased trauma from 
forceful manipulation and by allowing more thorough work, besides 
the avoidance of severing the nerves and its ill effects.” Additional 
experience of the past ten years affords no reason to change the 
previously expressed opinion. 

Certain usages have become established regarding the direction 
of incisions, structures to be conserved, etc. In this connection 
the following points should be considered: (1) The appearance of 
the resultant scar; (2) the relative importance of the division 
of muscular as compared with aponeurotic tissue; (3) conservation 
of the blood supply; (4) conservation of the nerve supply; (5) 
anticipated pathology; (6) the facility with which the incision 
may be closed; and (7) the relaxation afforded during and after 
operation. 

1. The Resultant Scar.—While the appearance of an abdominal 
scar is relatively unimportant, it is desirable that any incision be 
placed so that the scar will be as sightly as possible. Incisions 
along Langer’s lines result in the least objectionable scars. 


i Farr, R. F.: Abdominal Incisions, Journal-Lancet, November 1, 1913, 


388 


LOCAL ANESTHESIA IN SURGERY OF ABDOMEN 


2. Relative Importance of the Division of the Muscular as Compared 
with Aponeurotic Tissue.—Without going minutely into the question 
of the dynamics of the abdominal wall, certain points may be 
considered in this connection. Though the lateral pull on the 
abdominal wall may not be greater than the vertical, vertical 
tension is easily reduced by decreasing the distance between the 
ensiform cartilage and the pubes (Fig. 162). There is no way in 
which the lateral tension can be so diminished. The relative 
merits of muscular and aponeurotic tissue as supporting structures 
are still sub judice. A study of the structures of the abdominal 
wall shows that the bundle of fibers of aponeurotic tissue to a 
large extent lie transversely. It is a well-known fact that, even 




Fig. 162 . —Abdominal incisions. Showing method of relaxing abdominal wall in 

closing transverse incision. 


with marked diastasis of the rectus muscle, hernia does not occur 
without a separation of the aponeurotic fibers. Inasmuch as the 
aponeurotic tissue of the abdominal wall runs in a general trans¬ 
verse direction, and as lateral tension, which cannot be readily 
overcome, is apparently greater than the vertical, it would appear 
that Kocher’s 1 dictum that the rectus muscle is the least important 
structure of the abdominal wall may be correct. 

Two main objections are made to the division of the rectus 
muscle: (1) It is said that it retracts between the anterior and 
posterior sheaths and cannot be reunited unless some method is 
used to prevent this retraction, and (2) objection is also made that 
the hemorrhage is troublesome and is somewhat hard to control 


1 Chirurgische Operationslehre, 1907, J. Aufl. 












GENERAL CONSIDERATIONS 


389 


as it comes directly from the cut surfaces of the muscle. Perthes 1 
has advised the introduction of sutures on either side of the pro¬ 
posed incision, and it is not unusual to see those who employ this 
incision delay approximately ten minutes for the introduction of 
these sutures. From the author’s observation he must conclude 
that the procedure of suturing the rectus muscle to its sheath for 
the purpose of preventing its retraction is entirely unnecessary, 
though for the purpose of hemostasis it may be desirable. For 
many years he has observed the so-called retraction of the rectus 
muscle with the following results: 

W hen the incision strikes a transverse line, there is no retraction. 
In most instances the cut edges of the aponeurosis do not lie as 
near together as do the cut edges of a muscle. If the incision goes 
through the red muscle it is followed by some retraction, the degree 
dependent upon the distance of the incision from a transverse 
line. The end nearest the transverse line will show a certain 
amount of muscle projecting beyond the aponeurosis; the end 
farthest away may show a muscular retraction within the sheath, 
but in every case observed thus far there has been a positive 
amount of muscle beyond the edge of the aponeurosis; that is, 
the ends of the muscle were closer together than were the edges 
of the aponeurosis. In all cases examined a proper closure of the 
sheaths of the rectus (aponeurosis) has resulted in an intimate 
contact of the divided ends of the muscle. 

3. Conservation of the Blood Supply. —In the presence of suffi- 
cientlvfree anastomosis, the division of the bloodvessels is relativelv 
unimportant. Even with division of the main blood supply, 
incisions through extremely vascular areas heal with great rapidity. 
This is well illustrated in work about the face, and clinical experi¬ 
ence goes to show that the deep epigastric and inferior mammary 
arteries may be divided with impunity. 

4. Conservation of the Nerve Supply.—The abdominal wall is 
supplied by the lower thoracic nerves which travel obliquely down¬ 
ward and forward at the sides but enter the rectus muscle as large 
bundles in a transverse direction when they begin to subdivide 
into fine branches (Fig. 160). Unless made with extreme care the 
pararectal incision must destroy one or more of these nerves which 
are regarded by many authorities as the most important structures 
in the abdominal wall. Atrophy unquestionably results when 
any considerable area of the abdominal wall is deprived of its 
nerve supply. Numerous instances of weakness of the abdominal 
wall have been observed subsequent to the long pararectal inci¬ 
sion. The researches of Quain 2 would indicate that viscero-parietal 

1 Deutsch. Ztsehr. f. Chir., 1912, No. 37, 129 , 493. 

2 Trans. Western Surg. Assn., 1913, pp. 353, 369. 


390 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN 


adhesions are more prone to develop in cases in which the nerves 
of the abdominal wall have been divided. 

5. Anticipated Pathology.—Above the navel the transverse 
incision offers the most adequate exposure of the various pathological 
conditions. The gall-bladder, stomach and even the appendix if 
not adherent in the pelvis can be readily dealt with. In most 
instances retraction of the abdominal wall, both upward and 
downward, is possible, so that good exposure is usually obtained. 
By supplementing this incision with the near-midline vertical 
incision when necessary one is afforded perhaps the most ideal 
exposure it is possible to obtain. In the matter of choosing incisions, 
a great deal can be accomplished by varying the size and direction 
according to the pathology anticipated. 



Fig. 1G3.—Gall-bladder incision. Right rectus muscle exposed and mobilized. 

X X, marks linea alba. 


6. Facility with Which Incision May be Made and Closed.—All 

authorities agree that it requires more time to enter the abdomen 
by the transverse route. This is especially noted when Perthes’s 
method of muscle suture is employed or if the bleeding vessels in 
the severed muscles are clamped individually. With the method 
to be illustrated presently, however, the element of time is negli¬ 
gible. In closing, the procedure is relatively simple. One has 
to deal with two layers of aponeurotic tissue, and a point of utmost 
importance is the fact that the fibers of this tissue lie in bundles 
parallel with the line of incision, so that in closing one may pass 







GENERAL CONSIDERATIONS 


391 


the sutures around the fibers and avoid “cutting out,” which is 
not uncommon when closing the vertical incision. In closing the 
incision, the relaxation afforded by the proper posture of the 
patient makes it possible to unite the edges of the transverse cut 
in a relatively short time. When the vertical cut is added to the 
transverse, the strong lateral pull is at once encountered and the 
problem becomes more difficult. In this connection an important 
observation has been impressed upon the writer in comparing the 
tension upon the sutures used in the vertical cut with that upon 
those employed in the transverse arm of the “L” incision. In 
no instance has he found the lateral tension as easy to overcome 
as the vertical. The transverse incision always comes together 
more easily than the vertical. 

7. The Relaxation Afforded during and after Operation.—That 
one may obtain greater accessibility through the transverse incision 
than through the vertical incision of equal length is generally 
admitted, and most observers agree that there is less postoperative 
discomfort after the transverse incision. This is true and is prob¬ 
ably due to two important factors: (1) The better exposure afforded 
by the transverse incision allows the surgeon to do his work with 
less trauma, and (2) the line of incision may be relieved of tension 
to some extent by having the patient assume a proper posture (Fig. 
162). 


Technic. —The author wishes to outline the incision in the upper 
abdomen as he employs it, and call attention to the modifications 
commonly used. Generally speaking, the gall-bladder is exposed 
by a division of the right rectus muscle above the navel at a level 
which corresponds roughly to the lower border of the liver (Fig. 
163). The stomach is exposed by a division of the left rectus 
(Fig. 165). In each of these incisions the linea alba is crossed 
(Fig. 166). If the pathology lies high, the incision may be supple¬ 
mented by a vertical limb which may be extended to the ensiform 
if need be (Fig. 168). In making this latter, the linea alba is avoided 
as a matter of preference, and division is made of first the anterior 
and then of the posterior sheath of the rectus from 1 to 2 cm. from 
the linea alba (Fig. 164). In a large number of instances the appendix 
has been removed through the transverse gall-bladder incision 
without extending it. 

For the control of hemorrhage the methods illustrated (Figs. 
163, 164, 165, 166, 167) have been devised. A light, angular Fean 
forceps is placed with one blade behind the muscle, the other in 
front and made to include the aponeurosis. The muscle is divided 
between these clamps, which are allowed to remain throughout the 
operation. The upper segment of the muscle is gently loosened 
from the transversalis, which is then split in the direction of its 


392 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN 


fibers, or, as Meyer 1 has suggested, it may be divided in a diagonal 
direction corresponding in its course to the Ivoeher gall-bladder 



Fig. 164. —Gall-bladder incision. Right rectus divided between muscle clamps. 

Curved incision of posterior sheath. 



Fig. 165. —Gall-bladder incision (left). Stomach and spleen incision (right). 

X X, marks linea alba. 

1 Transverse Abdominal Incisions, Ann. Surg., 1915, 62 , 573-575. 

























GENERAL CONSIDERATIONS 


393 


incision. The author’s preference is for a curved incision in the 
posterior sheath which in a general way follows the line of the incision 



Fig. 166.—Trans-rectus incision across both muscles. 
X, marks linea alba. 



Fig. 167.—Trans-rectus incision completed. Note exposure. 


in the anterior sheath 
midline and slightly 


. It is, however, somewhat farther from the 

higher than the one in front of the rectus. 
© 




































394 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN 


The posterior flap, therefore, has a curved rather than a rectangular 
form (Fig. 164). 

Drainage is established by means of a stab-wound, generally 
above the incision in the flap, but below in case the drainage tube 
would more naturally lie in this position. Postoperative hernia 
is in this way guarded against to some extent. Enthusiastic 
reports concerning the transverse incision might lead to the belief 
that hernia does not occur following it. The author’s experience 
shows that hernia may take place in cases that suppurate or in 
which drainage has been carried out through the incision proper. 
He has had no hernia in cases that healed primarily, and 
his impression is that hernia is less liable to occur when the trans¬ 
verse incision is employed. 



Fig. 1G8. —Gall-bladder incision. Closure; drainage through stab-wound. 

X, linea alba. 


Closure.— A mattress suture (Fig. 168), continuous or interrupted, 
closes the peritoneum and transversalis muscle, everting the former 
and taking up some of the slack in the posterior sheath, thus aiding 
in the approximation of the cut ends of the muscle. The anterior 
layer may be imbricated, provided this is necessary, in order to 
approximate the muscle, using a continuous or interrupted mattress 
suture (Fig. 169). 

The vertical incision still holds the fort, especially in large clinics 
where old customs are wont to linger longest, though certain modi¬ 
fications are being made with increasing frequency. The past 






general considerations 


395 


six years have witnessed a vast change in this regard. It is most 
significant that those who have seen fit to try the transverse incision 
ev en a limited number of times are prone to resort to it rather 
frequently. Boeckman 1 was a pioneer in the use of the transverse 
incision. He does not hesitate to divide the rectus muscle either 
above or below the navel. During recent years, Moschcowitz 2 
has made rather extensive use of the incision, and recently Lilienthal 3 
has been favorably impressed with it. Willy Meyer favors com¬ 
bining the transverse wdth the vertical incision in the midline, 
dividing the transversalis and peritoneum diagonally after raising 
the rectus muscle. Quain 4 reports several hundred cases in which 
he has used the transverse incision wdth great satisfaction. 
McArthur’s 5 incision, when used for the cases for which he recom- 



Fig. 169.—Sectional view of abdominal wall after closure. 


mends it, is excellent. It conserves the blood supply, muscle, 
aponeurosis and the very important nerve supply. One should 
not hesitate to change it to the transverse or vertical in case more 
room is needed. The writer has chosen a transverse skin incision 
when using it. 

The impunity with w r hich the rectus muscle may be divided 
should be kept in mind by all surgeons. If the advantage of this 
point is utilized in certain cases an excellent exposure may often 


1 Transverse Abdominal Incisions, St. Paul Med. Jour., 1910, No. 12, p. 255. 

2 Transverse Incisions in the Upper Abdomen, Ann. Surg., 1916, 64 , 268-289. 

3 Discussion, Trans. Am. Med. Assn., 1917, p. 1845. 

4 The Transverse Incision in the Upper Abdomen, Journal-Lancet, 1917, 37 , 657. 

5 A Modified Incision for Approaching the Gall-bladder, Surg., Gynec. and Obst., 
1815, 20 , 83-84. 





























396 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN 


be obtained, which with the vertical incision is impossible, and 
frequently an almost impossible proposition may be converted 
into a smooth, easy operative procedure. One should not become 
wedded, so to speak, to any particular incision. In certain types 
the vertical, Robson’s or Bevan’s modification of the same gives 
the best possible exposure. In the broad, flat, corpulent type 
the trans-rectus cut will afford the best approach. The advantages 
of the vertical cut may be used if desired. The practice of vary¬ 
ing the incision to suit the case, depending upon the conformation 
of the patient’s body and the pathological problems present, has 
given the greatest satisfaction. Recently a cholecystectomy was 
done through the classical McBurney appendix incision made well 
below the navel as the gall-bladder lay in this position. 



Fig. 170.—Viscero-parietal adhesions. Vertical retraction. 


When making abdominal incisions it is desirable in many instances 
to avoid pressure upon the underlying structures. Acute cases, ner¬ 
vous people or children, demand that the abdominal wall be lifted 
while incising. The skin may be grasped with towel pins (Fig. 
212, page 490) and after its division and the nicking of the fascia 
this structure may also be elevated. Likewise the peritoneum 
may be gently retracted and when opened the abdominal wall 
may be elevated by placing a retractor beneath its surface (Fig. 
170). This demands the careful anesthetization of the peritoneum 
to a point some distance away from the incision. One need not 
hesitate to reinforce the anesthesia by introducing the needle 


GENERA L CON El DERA Tl ONE 


397 

subperitoneally after the abdomen is opened for the purpose of 
injecting the solution. 

The Making of the Incision. — Technic.—When making the 
incision one can readily note the general contour of the patient’s 
abdomen and the tension under which the muscles are laboring, 
and can gauge quite accurately the course of events which will 
ensue directly the peritoneum is incised. The amount of com¬ 
plaint and resistance offered by the patient’s tissues may also be 
noted; in fact, a general observance of the operative field will fre¬ 
quently enable the surgeon to note in advance whether or not he 
has obtained complete anesthesia. The muscle whose nerve supply 
has not been blocked will demonstrate that it is still “awake” 
by undergoing a contraction when it is attacked. This will often 
permit the surgeon to anticipate complaints on the part of the 
patient, and when this contraction does take place the evidence 
that more anesthesia is required in this locality should be heeded. 
By so doing one may frequently avoid causing the patient suffi¬ 
cient pain to bring out a complaint. It is, in other words, a 
more delicate sign than having the patient complain vocally of 
pain. If, as has already been said, when the peritoneum is 
approached one notes by the signs mentioned above that the 
abdominal viscera will protrude because they are held under 
pressure when the peritoneum is opened the procedure had better 
be given up as a failure and general anesthesia administered. On 
the other hand, if proper relaxation obtains, the peritoneum may 
be opened between forceps which are steadily retracted upward with 
some degree of force. It is essential when incising the abdominal 
wall to use some form of automatic retraction so that a perfect 
exposure may be secured without too much manipulation of the 
tissues (Fig. 214, page 492). Under ideal anesthesia the condition 
differs little from that found in a fresh cadaver at autopsy. As 
soon as the peritoneum is nicked the air enters the peritoneal 
cavity and the force of gravity carries the viscera to the lowest 
possible level away from the abdominal incision. (See page 147.) 
Favorable pelvic cases, when placed in the Trendelenburg position, 
with “ideal” anesthesia and a properly retracted abdominal wall, 
will show no small intestine below the pelvic brim. The left 
lateral tilt and a slight Trendelenburg will show the cecum and 
terminal ileum lying 4 or 5 cm. away from the abdominal wall 
without the necessity for any search whatever. (Fig. 202, page 
473.) In the upper abdomen the lower portion of the stomach, 
duodenum and gall-bladder and the transverse colon may be 
inspected at leisure without withdrawing any of these organs from 
the abdominal cavity and without the placing of sponges. The 
author has termed this ideal condition, which is really the “answer” 


398 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN 


in abdominal surgery under local anesthesia, “negative pressure ’ 
and its degree vividly portrays in each case the manner in which 
the anesthesia has been introduced and the care with which the 
abdominal wall has been opened. Negative pressure is the reward 
one receives for applying proper technic when entering the abdomen. 
Positive pressure , the protrusion of the viscera and failure mean, 
as a rule, faulty technic. 


Muscular Relaxation.—Duties of the Psycho-anesthetist (See also 
page 160).—While the abdomen is being opened much may be done 
to bring about the ideal condition of complete muscular relaxation 
which is so essential for successful intra-abdominal surgery. An 
adjunct of vital importance is the “psycho-anesthetist" who sits 
at the patient’s head during the operation and looks after his com¬ 
fort and records the blood-pressure, pulse and respiration. Tactful 
cooperation on the part of this individual will be found of great 
assistance. In addition to her other duties her efforts should be 
directed especially toward aiding in securing relaxation. Again 
let it be stated emphatically that complete muscular relaxation 
must always be the goal toward which the surgeon should strive 
if he is to attain the greatest success in this work. The tension 
which is always present when a patient winces and struggles under 
the manipulation of the surgeon prevents the complete abdominal 
relaxation so necessary for the proper performance of any abdominal 
operation. The surgeon must realize, when attempting laparotomies 
under local anesthesia, that success can be obtained only by the 
use of a technic which permits of relaxation. The author contends 
that such relaxation may be obtained in most cases, and perhaps 
in all, provided one’s technic is sufficiently good. For those who 
are not able to secure this relaxation in a reasonable percentage of 
cases, abdominal surgery under local anesthesia will continue to 
be a Herculean task, and as a consequence they will quite probably 
continue to condemn the method in the future as they have in the 
past. It is hoped that a more universal realization of the facts 
will change the attitude of that large percentage of surgeons who 
maintain that only certain classes of cases should be undertaken 
under local anesthesia and will convince them that almost all 
classes of cases can be operated upon successfully by this method 
and that it is already being done daily by those who are accomplished 
in this art. 


As a rule, when the abdomen of an apprehensive patient is 
uncovered upon the operating table the tension under which he 
is laboring will be plainly manifest. The abdominal muscles, 
instead of being relaxed, will be tense and rigid and the normal 
depressions which show when a patient is at rest will be absent. 
This is most plainly seen when the Trendelenburg position is 


GENERAL CONSIDERATIONS 


99 


assumed. Here the relaxed individual will present a depression 
in both iliac fossae. The pubes and anterior-superior spines will 
be prominent and the upper abdomen will bulge forward, as it 
will contain most of the viscera. In the tense patient this con¬ 
dition does not obtain. The recti are contracted and stand out 
as ridges on either side of the midline. Contraction of the lateral 
groups obliterates the depressions normally found below the navel, 
and it is evident that the viscera have not gravitated to the more 
dependent portions of the abdomen. I nless this condition can 
be overcome by the introduction of the anesthetic with the aid 
of suggestions and instructions from the psycho-anesthetist, who 
coaches the patient in regard to his manner of breathing and the 


avoidance of straining, grunting, coughing or laughing, general 
anesthesia had better be administered before the peritoneum is 
finally opened. Few operations can be performed without relax¬ 
ation. Certainly under such conditions none can be performed 
painlessly, and a painful operation is neither fair to the patient 
nor to the method, and should not be performed. 

Abdominal Exploration.— Perhaps the most potent argument in 
relation to the question of local versus general anesthesia in ab¬ 
dominal work—at least in the minds of the surgeons who favor 
general anesthesia—relates to the question of abdominal explora¬ 
tion. While there is undoubted truth in the statement that wide ab¬ 
dominal explorations are facilitated by the use of general anesthesia 
more than by the use of local, those who are familiar with the 


use of local anesthesia realize the fact that with increasing experience 
abdominal explorations may be made in a fair percentage of cases. 
It must be admitted that the abdominal exploration is, as a rule, 
a substitute for a complete diagnosis, and it is accepted. I think, 
that it should not be made in anv case in which it can be 

1/ 

avoided. A more earnest effort at its avoidance would undoubtedly 

«/ 

result in a reduction of the number of abdominal explorations and 
with great benefit to surgical patients. Furthermore, in the author’s 
experience it has been unusual to find gross surgical pathology 
which could be recognized upon blind exploration with the gloved 
hand which could not be rather accurately anticipated after all 
points in the patient’s history, a thorough physical examination 
and a proper collaboration of laboratory data had been coordinated. 
Better surgery demands the elimination of the extensive blind 
exploration of the abdominal cavity, as far as possible. Obscure 
cases will always demand such exploration. However, an effort 
to cure the patient should relate especially to his symptoms and 
surgeons should make it a rule to anticipate the particular path¬ 
ology for which they are opening the abdomen. 

The author has little patience for instance, with the surgeon who 


400 LOCAL ANESTHESIA IN SURGERY OF ABDOMEN 


at 8 a.m., opens the lower abdomen for the performance of some 
pelvic operation and blithely introduces his gloved hand into the 
upper abdomen, turning his back to the patient the while, and 
reports that the right kidney, the left kidney, the spleen, the gall¬ 
bladder, the common duct, the pancreas, the stomach and the 
duodenum, each in its turn, is entirely normal, while within an 
hour the same surgeon may be seen to open the upper abdomen 
and spend ten, twenty or thirty times as long going over similar 
organs of another patient and yet be unable to decide whether or 
not pathology is present—a point he decided an hour before without 
the use of his eyes and without the slightest hesitation. Take, 
for instance, the simple question of the presence or absence of 
gall-stones within the gall-bladder. On numerous occasions a 
distended gall-bladder after its removal has been passed to visiting 
physicians to find that they have had the greatest difficulty in 
stating whether or not there were gall-stones present. Again on 
frequent occasions the author himself has been unable to decide 
this question positively before emptying the gall-bladder; and he 
has been surprised to find scores of small stones in a gall-bladder, 
which had previously been palpated with negative results. 

One feels, therefore, that the argument that abdominal explor¬ 
ations cannot be carried out under local anesthesia must be largely 
discounted for the above-mentioned reasons. First, that the blind 
abdominal operation should be limited as far as possible; and 
second, that when it is necessary it may be quite successfully made, 
provided the proper local anesthesia technic is followed; and third, 
mixed or psycho-local anesthesia may be added while the exploration 
is being made, provided this becomes necessary. (See pages 78 
and 79.) 

The Examination of the Abdominal Organs.—The comparative 
ease with which the abdominal organs may be examined under 
conditions of complete relaxation, as contrasted with the difficulty 
encountered in making such an examination under the conditions 
usually seen when watching abdominal operations, may be 
brought out by comparing of the inspection of a herd of live stock 
under varying conditions. Under ideal conditions we would 
open the barnyard gate and look over a herd of live stock resting 
peacefully within the enclosure. The condition of each would be 
noted, even though an occasional one might need to be moved 
about in order to obtain a better view. If, on the other hand, 
when the gate is opened the whole herd, or a goodly portion of it, 
rushes headlong into the gateway and must be forcibly restrained 
the inspection cannot be detailed or satisfactory. This com¬ 
parison, though a homely one, is nevertheless not greatly over¬ 
drawn. 


GENERAL CONSIDERATIONS 


401 


I he superiority of visual over digital examination has been 
discussed elsewhere and nowhere does it apply more aptly than 
in abdominal surgery. Though much valuable information may 
be gained by palpation, inspection is and will always remain the 
great purveyor of the facts concerning the actual conditions pres¬ 
ent. I nfortunately, there is a class of cases in which a negative 
intra-abdominal pressure cannot be obtained, regardless of the 
form of anesthesia used, and here we must depend to a large extent 
upon other senses than that of sight. A discussion of the mode 
of procedure in case a proper exposition of the internal organs 
cannot be brought about will be taken up later. For the present 
we will concern ourselves with cases which are classed as amenable 
to the technic described above. 

Viscero-parietal Adhesions.— Yiscero-parietal adhesions are 
usually considered somewhat difficult to handle under the use of 
local anesthesia, and indeed are usually considered sufficient reason 
to contraindicate its use. Nothing could be further from the 
facts if the author’s own experience may be taken as a criterion. 

The adhesive bands themselves are without sensation, and 
provided the abdomen is opened without pain, with perfect relaxa¬ 
tion, under a negative intra-abdominal pressure, and its wall 
lifted vertically as the peritoneum is opened the adhesions will be 
visualized exactly as at autopsy, and may be cut upon the “ white 
line,” where they join the parietal peritoneum. x4s traction upon 
the parietal peritoneum causes pain the vertical retraction of the 
abdominal wall should be carefully graduated. The weight of 
the piece of intestine or other viscus which may be suspended 
from the abdominal wall may be sufficient to cause the patient 
discomfort. However, if one lifts the abdominal wall to a slight 
degree only the adhesions may be visualized and the anesthetic 
introduced into the pro-peritoneal fat by introducing the needle 
through the abdominal wall or from the peritoneal side (Fig. 170). 

Viscero-visceral adhesions may be divided without the use of 
intraperitoneal anesthesia. The only requisite is the avoidance 
of traction upon the posterior parietal peritoneum, and even this 
structure tolerates sufficient traction to allow one to identify the 
retaining bands, which may then be divided with a scalpel or 
scissors. 

Exposure and the absence of expulsive effort are the prime 
essentials in meeting the surgical demands in these conditions. 
The abolition of the abdominal reflexes, vertical retraction, tilting 
of the table combined with a negative intra-abdominal pressure, 
the cooperation of the patient and the judicial use of local anes¬ 
thetic solutions will make it possible for one to meet the indications, 


26 


CHAPTER XIV. 


LOCAL ANESTHESIA IN SURGERY OF THE 
ABDOMINAL WALL (HERNIA). 

HERNIA. 

The operation for inguinal hernia illustrates one of the early 
applications of local anesthesia to major surgery. Its easy estab¬ 
lishment, simplicity, safety and the opportunity offered for the 
performance of a perfect anatomical reconstruction under ideal 
conditions have made its acceptance widespread. However, we 
still find much objection to it on a variety of grounds. 

Psychic incompatibility is said to contraindicate its use. Alexis 
v. Moschcowitz, for instance, states that when working under local 
anesthesia, the surgeon is handicapped and lacks the opportunity 
to do thorough work. He considers it satisfactory for the simpler 
cases, but for the large or complicated hernise he recommends general 
anesthesia. In the experience of the author, the size of a hernia 
modifies in no manner the technic, as the nerve supply is the same 
whether it is large or small. Incisional hernia and umbilical hernia, 
no matter how large or how complicated, are among the simpler 
operations under this method of anesthesia. It is difficult to find 
any condition which is better adapted to the use of this form of 
anesthesia than is hernia of the abdominal wall. 

Inguinal Hernia.— Nerve Supply. —(Fig. 160, page 380; and Plates 
IX and X.) The nerves involved in this operation are those supply¬ 
ing the skin, the inguinal canal and its region, the scrotum in the 
male and the labium in the female. 

The skin, fascia and muscles of the inguinal region are supplied 
by the anterior cutaneous branch of the twelfth thoracic nerve, 
the iliohypogastric (n. iliohvpogastricus I. L.) and the ilioinguinal 
(n. ilioinguinalis I. L.). The skin just beneath the ilioinguinal 
ligament is supplied by the lumboinguinal branch of the genito¬ 
femoral nerve I. II. L. 

The cremaster is supplied by the external spermatic (n. sper- 
maticus externus) or genital branch of the genitofemoral nerve, 

I. II. L. 

The cord is supplied by the spermatic plexus of the sympathetics 
from the pelvic plexus and also contains the genital branch of the 
genitofemoral mentioned above as it passes to the scrotum. 


HERNIA 


403 


The scrotum is supplied by the nerves mentioned under hydrocele 
(see page 344). They are the ilioinguinal (n. ilioinguinalis I. L.), 
the external spermatic (n. spermaticus externus) of the genito¬ 
femoral and the inferior pudendal or long scrotal branch of the 
posterior femoral cutaneous (n. cutaneus femoralis posterior I. 
II. III. S.). 

The nerve supply of the labia is derived from the ilioinguinal 
(n. ilioinguinalis I. L.) and the posterior labial (nn. labiales posteri- 
ores) or superficial perineal branches of n. pudendus II. III. IV. S. 

Skin Sterilization.—The problem of skin sterilization becomes an 
important one when performing the operation for inguinal hernia 
under local anesthesia, as the application of many of the antiseptics 
in use will, if allowed to reach the scrotum or labia, give rise to 
discomfort. This contingency may be met in the following manner: 
The solutions may be painted upon the skin until the border of the 
sensitive area is reached and this area may then be anesthetized 
by a subdermal infiltration through the needle which has pierced 
the skin well above the danger line. As soon as anesthesia is 
established a protective towel or gauze pad may be securely anchored 
to the skin below the external ring, thus effectually excluding the 
unsterile field from the field of operation. 

The Induction of Local Anesthesia.—It is usually possible to 
establish such perfect anesthesia in these cases that no reinforce¬ 
ment is necessary after the operation is begun, and while there is 
no great objection to blocking the nerves as they appear or to using 
an additional amount of the solution should the patient complain 
of pain at any time during the operation, we have usually con¬ 
sidered the necessity for this an indication that the technic has been 
somewhat defective. 

The technic for establishing anesthesia for surgical repair is 
as follows: 

The initial wheal (Fig. 171) is made at the outer end of the pro¬ 
posed line of incision A, and from here the subdermal infiltration 
is made along this line B. As the region over the external ring is 
reached the injection is carried down into the scrotum or labia, 
as the case may be, and 10 to 15 cc deposited here, C. From the 
initial wheal the needle is now carried to a point 2 cm internal to 
the anterior-superior spine I), and another intradermal wheal is 
made here from beneath. Through this wheal the remainder of the 
anesthetic solution is introduced. The needle is inserted vertically 
until it is felt to pierce the aponeurosis of the external oblique and 
at this point a fairly large amount (approximately 30 cc) of solution 
is deposited (Fig. 171). The two nerves, n. ilioinguinal and n. 
iliohypogastric, here lie upon the internal oblique muscle and will 
be bathed by the solution as it is injected between these layers, 


404 


SURGERY OF THE ABDOMINAL WALL 


The next step is the infiltration of the peritoneum (Fig. 171, insert 
“fluid”), catching the terminal nerves from the eleventh and 
twelfth thoracic at the same time, which come down from above. 
This injection is made by passing the needle down through the 
internal oblique and, while advancing slowly, building a wall of 
anesthesia transversely from Poupart’s ligament laterally to the 
edge of the rectus muscle. For the average case a total from 60 to 
90 cc of solution is ample but good anesthesia requires that a liberal 
infiltration be made. This is not meant to indicate that one should 
needlessly inject the solution into the tissues. 



Fig. 171.—Inguinal hernia. Anesthesia technic. A, B, C, subdermal infiltration; 
D, wheal for deep infiltration. Insert: Sectional view of same. 


The time required for making the injection is from two to five 
minutes and the incision mav be made without delay. The skin 
may be elevated with towel clips (Fig. 212, page 490.) Sharp 
dissection should be the rule. The Trendelenburg position will 
aid in ridding the sac of its contents and a perfect exposure may be 
had by the application of the automatic spring retractors. No 
surgeon should allow himself to be handicapped by incomplete 
anesthesia nor should he blame his patient or the solution if he 
finds himself in trouble. The margin of error when the proper 
technic is followed is very slight and when trouble arises it is usually 
an easy matter to fix the responsibility. The operation the author 




HERNIA 


405 


employs is that described by Torek, in which the vas deferens is 
separated from the vessels and, as this operation comprehends 
going well into the abdominal cavity, it should be the most severe 
test to which the method could be put in the treatment of inguinal 
hernia. 



Fig. 172.—Inguinal hernia. Photograph of Case No. 13402, during operation. 

Cord, veins and sac presenting. 



Fig. 173.—Inguinal hernia in children. Photograph of boy, aged four years, 

during operation. 


Fig. 172 shows a patient undergoing an operation. The sac, 
vas and veins are shown in the photograph of Case No. 13402. 
Children may be operated upon with great satisfaction under this 
method. 

As previously stated children may be bribed or coaxed into good 










400 


SURGERY OF THE ABDOMINAL WALL 


behavior and they often attempt to “show oft” during the operation. 

(Fig. 173). ' . 

This shows a boy aged five years of whom a motion picture has 
been shown before a number of medical conventions. It is one of 
the early cases. 

As an example of multiple operations and the possibility of 
meeting complicated conditions the following case may be related: 

Report of Case No. 15652. 

S. C. D., male, aged four years and nine months; entered hospital 
April 7, 1922; referred by Dr. H. G. Franzen. 

Diagnosis: Bilateral undescended testicle; bilateral oblique 
congenital inguinal hernia; phimosis. 

Operation: Bevan operation for replacement of testicles; Ferguson 
repair of inguinal hernia; circumcision. 

Anesthesia: Local infiltration 90 cc novocain-adrenalin solution. 

Operation: The method of restraint illustrated in Fig. 181, page 431, 
was applied but its use was found unnecessary. An infiltration block 
as illustrated in Fig. 171, page 404, was employed, 90 cc of a 1 per cent 
novocain-adrenalin solution being used. The psycho-anesthetist 
was supplied with five silver dollars as a bribe for the purpose of 
obtaining godd behavior on the part of the boy during the operation. 
The testicles were placed in the scrotum, bilateral hernial repair 
accomplished and circumcision performed without remonstrance on 
the part of the boy. For technic of infiltration for circumcision see 
page 340. Primary healing followed. The patient left the hospital 
on April 22, ten days after the operation. 

Femoral Hernia.— For this operation the blocking is even more 
simple than for inguinal hernia. One must be prepared, however, 
in a strangulated femoral hernia to bring the bowel out above for 
resection and this procedure will be considered under strangulated 
hernia. A transverse block down to the peritoneum is made on a 
line corresponding to the external inguinal canal and, in addition, 
the line of incision is blocked in the usual manner. It is well to 
make a deep infiltration external to the femoral canal to catch the 
branches of the femoral nerve (n. femoralis). (II. III. IV. L.) 

Incisional Hernia.— In the production of anesthesia in incisional 
hernia the infiltration for simple laparotomy is practically multiplied 
by two. The injection should be made rather wide of the scar and 
bilateral in order to avoid the possibility of visceral puncture. 
In case there are parieto-omental or visceral adhesions present, and 
there usually are, they may be readily exposed by making vertical 
retraction, and a subperitoneal infiltration should precede the 
cutting of these attachments (Fig. 170, page 396). A perfect negative 


HERNIA 


407 


pressure and vertical retraction will show the adherent intestine or 
omentum hanging from above much like bunting hanging from a 
ceiling. 

r l he following case will illustrate the application of local anes¬ 
thesia in the repair of large incisional hernise: 

Report of Case No. 13908. 

I). A. A., physician, male, aged thirty-four years, entered the 
hospital July 21, 1920. 

Diagnosis: Incisional hernia. 

Operation: Herniotomy. 

Anesthesia: Circumferential infiltration block. 

History: This patient had been operated upon one year previously 
for acute appendicitis and presented a large right rectus incisional 
hernia. 

Anesthesia: A circumferential infiltration was made about the old 
line of incision, blocking from the costal margin on the right to the 
anterior superior spine. 120 cc of a 0.5 of 1 per cent novocain- 
adrenalin solution were used. 

Operation: The old scar was excised and the abdominal cavity 
opened with the patient in the Trendelenburg position and tilted to 
the left. A negative intra-abdominal pressure was secured. The 
colon and small intestine were found adherent to the anterior 
abdominal wall. The adhesions were cut upon the white line, no 
ligatures being required. The abdominal layers were identified 
and closed with imbrication. 

The operation was entirely painless. The patient vomited once 
while being returned to bed. He made an uneventful recovery. 

Note .—'Phis patient came with the request that the operation be 
performed under local anesthesia on account of his former experience 
with general anesthesia. 

Transplantation of Fascia. —In some cases it may be necessary 
to introduce fascia on account of the great attenuation of the tissues 
of the abdominal wall. At first thought this might be considered a 
contraindication to the use of local anesthesia. However, the 
preparation of the field for the removal of a transplant of fascia is an 
exceedingly simple procedure. It requires only the outlining of a 
skin incision on the thigh by a subdermal infiltration and an injec¬ 
tion into the fascia along the line where it is to be excised. With 
proper equipment but two minutes are required for the establish¬ 
ment of anesthesia for the taking of fascial transplant. It is an 
absolutely painless procedure and exceedingly easy of accomplish¬ 
ment. 

Hernial defects in the upper abdomen demanding transplantation 


408 


SURGERY OF THE ABDOMINAL WALL 


of fascia may be repaired by the pedicle flap method, an intercostal 
block being made in the mammary line bilaterally and made 
sufficiently high to permit dissection of the flaps. The following is 
a description of a method of dealing with this class of cases, which 
is reprinted from Surgery, Gynecology and ObstetricsA 

“The closure of defects in the abdominal wall has presented 
difficulties to surgeons and many ingenious methods have been 
devised in an effort to bring about a cure in this class of cases. 
Silver wire, silver chain, linen, silk, plastic methods, and the intro¬ 
duction of grafts of bone and fascia have been utilized—the most 
satisfactory perhaps being the transplant of fascia lata from the 
thigh. While in the absence of infection these grafts, as a rule, 
live and heal in place, their nourishment must come from surround¬ 
ing tissues, thus placing a rather severe strain upon one’s asepsis. 
The presence of slight infection is apt to be inimical to success. 
It would seem desirable to use, whenever possible, a transplant of 
fascia, or fascia and muscle combined, whose circulation is not 
entirely cut off'.” 

The following cases, presenting defects in each instance larger 
than one’s open hand, permitted the writer to make use of the 
method described below, and in each instance resulted in a perfect 
closure of the defect. 

Case I.—Mrs. M. M., aged fifty-five years, weight 250 pounds, 
extremely adipose. The writer had operated upon this patient in 
1905 for cholelithiasis, a cholecystostomy being done. In May, 1914, 
a large amount of gangrenous bowel was turned out through an 
incision at the ninth costal margin on the left. A resection was 
done later, with a lateral anastomosis of the colon, drainage being 
required. A year later, 1915, the gall-bladder was removed on 
account of cholecystitis and cholelithiasis. There was practically 
no muscular tissue left in the upper abdominal wall and a hernia 
resulted over the area shown in Fig. 174 (1.) 

This figure, a composite drawing of Cases I, II and III shows 
the relative size and position of defects, and also the approximate 
size of pedicle flaps and locations from which they were obtained. 

The next fall, 1916, she was operated upon for repair of her hernia. 
The abdominal cavity was opened by an incision 30 cm. in length, 
and the edges of the aponeurosis identified. The viscero-parietal 
adhesions were carefully freed and all raw surfaces excluded. 
There now presented a defect 10 cm. in width and approximately 
25 cm. long, extending from one costal margin to the other and well 
below. A vertical incision was made over the sternum, and the 

1 Farr, Robert Emmett: Closure of Large Hernial Defects in the Upper Abdo¬ 
men, Surg., Gynec. and Obst., February, 1922, pp. 264-265. 


HERNIA 


409 


sheath of the pectoral muscles exposed as high as the nipple line 
(Fig. 175). A quadrangular flap 25 cm. long with the base below and 
composed of pectoral fascia and a considerable amount of muscle 
was dissected downward until a flap approximately 15 cm. in width 
had been raised. This flap was then sutured over the hernial 
opening, chromic gut being used. 



Fig. 174.—Incisional hernia. Pedicle-flap and fascia transplant. 1, 2, and 3, 
shows defects and outlines of flaps for covering same. 


Case II.—Mr. L. C., aged seventy-three years, operated upon 
January 15, 1921. This patient had had six operations in the 
upper abdomen by other surgeons for alleged gastric trouble, and 
presented a large hernia extending from the umbilicus to the 
ensiform, the defect being about 10 cm. wide and 15 cm. long. (Fig. 
174 (2)). The patient had suffered extreme distress upon taking 
food and belched continually. 

Operation: The aponeurotic edges were freed, the viscero-parietal 
adhesions and all raw surfaces were carefully covered. In this case 
there was no parietal peritoneum with which to close the abdomen. 
After the application of tension sutures the incision presented a 







































410 


SURGERY OF THE ABDOMINAL WALL 


defect 10 by 15 cm. The procedure illustrated was carried out. 
The flap taken from the chest wall was applied to the upper portion 
of the defect. The aponeurosis of the external oblique was employed 
to complete the closure (Fig. 174, (2) ). A pedicle flap with a mesial 
base was turned in from either side and overlapped at the midline. 
(See insert Fig. 175.) This patient has remained entirely well and 
is greatly improved symptomatically. 



Fig. 175.—Incisional hernia. Pedicle-flap and fascia transplant. Shows flap 1 
(Fig. 174), sutured in place. Insert: shows 2 (Fig. 174), with flaps sutured in place. 

Case III.—Mrs. W. A., aged fifty years. On April 22, 1920, a 
eholedochotomy was performed for the relief of chronic jaundice 
due to an impacted stone. On May 9 the patient developed severe 
hemorrhage from the wound. Blood transfusion decreased the 
clotting time of the blood and a massive pack prevented further 
hemorrhage. Subphrenic abscess with infection of the pleura was 
diagnosed on June 3, when posterior drainage with rib resection was 










HERNIA 


411 


done. Lung abscess developed on May 18, so that the patient had 
communication between the bronchus and the opening in the 
abdominal wall. The patient slowly recovered and returned to the 
hospital on March 30, 1921, for repair of a massive incisional hernia 
which had taken place through the L-incision for the original gall¬ 


stone operation. 

Operation: The abdominal wall presented no muscular tissue and 
a fair amount of tension upon the aponeurotic edges left a defect 
approximately the size of one’s hand (Fig. 174, (3) ). In this case a 
rectangular flap with the base lying along the costal margin, its 
lower portion utilizing the upper part of the external oblique on the 
right, was turned down from the chest wall and with it the defect 
was effectually closed as in Fig. 175. 

In each of these cases drainage was employed for twenty-four 
hours, and in Case III a slight suppuration took place at the upper 
angle of the wound. The patient, however, apparently has a 
splendid abdominal wall, although the time is too short for one to 
feel at all certain about a permanent result. 

The lower portion of the thorax furnishes one with the ideal 
conditions for the procuration of a pedicle flap as the protection of 
the ribs furnishes adequate insurance against the possibility of 
weakening the area from which the flap is obtained. The pedicle- 
fiap method, provided flaps can be obtained without too greatly 
reducing the strength of the area from which the flaps are obtained, 
may be effectually applied to ventral hernia in any part of the 
abdominal wall. 

Epigastric Hernia.—Epigastric hernia presents no difficulties 
and is one of the most simple procedures under local anesthesia. 
A circumferential infiltration block only is required. In performing 
operations of this nature adequate exposure should be insisted upon 
by making an adequate incision. 


Umbilical Hernia and Lipectomy.—The technic which the author 
has employed in operations for the repair of umbilical hernia has 
depended upon the surgical problem which presented itself for 
solution. Much will depend upon the dimensions of the hernia, 
and whether or not lipectomy is to be performed at the same time. 
Simple small hernise may be operated upon following a circum¬ 
ferential subdermal infiltration, plus a circumferential edematization 
of the fascia and peritoneum. The subcutaneous fat, which is 
usually abundant, need not be infiltrated. The infiltration of the 
layers should be made at some distance from the borders of the 
hernial tumor. The amount of solution necessary in the case of a 
small hernia is not great. Cognizance should be taken of the fact 
that the hernial sac may extend some distance beneath the skin 
and assume a more or less mushroom shape. Under these condi- 


412 


SURGERY OF THE ABDOMINAL WALL 


tions careless introduction of the needle too close to the apparent 
limits of the sac may result in the puncture of the contents of the 
sac with the consequent spread of infection. Should there he the 
slightest doubt, or should one’s experience be limited, it is perhaps 
desirable to defer the injection of the fascial and peritoneal layers 
until they have been exposed in the incision. The subdermal 
infiltration of the skin along the lines of incision will allow one to 
incise down to the fascia and thus avoid the possibility of introduc¬ 
ing the needle into the intestine. In the case of large or complicated 
hernise, especially where lipectomy is to be performed, the following 
procedure has been devised: 

The line of incision is carefully marked out upon the abdominal 
wall by the use of a sponge saturated in iodine solution, or if iodine 
has been used upon the skin for the purpose of sterilization a sponge 
saturated in alcohol will answer the purpose. The line for the 
upper incision is curved rather sharply downward at its extremities. 
This line is now anesthetized by the method described in Fig. 31, 
page 149, a 10 cm. needle being used. Following the subdermal 
infiltration along the upper line only, an incision is made through 
the skin and fat until the fascia is brought into view. As the fascia 
is approached some care must be exercised as the fat which lies in 
close proximity to this tissue contains some sensory nerves, especially 
in the region of the large perforating vessels. The skin is now 
protected, and a subfascial infiltration quickly made at the bottom 
of the incision. At the extremities of the incision the needle is 
directed downward along the abdominal wall, beneath the fascia, 
and in this manner a transverse block is established with resulting 
anesthesia of that portion of the abdominal wall below the incision. 
The upper segment of the fat about the sac is now dissected well 
downward until at least half of the neck of the sac is identified. 
One may now complete the lower portion of the incision, as anes¬ 
thesia of this region will be found to be complete and the remainder 
of the operation may be carried out without embarrassment. 
Vertical retraction of the abdominal wall will usually suffice for the 
return of the contents of the sac into the abdominal cavity. 

As an example of the application of the above technic, the follow¬ 
ing Case Report No. 14590 is presented. This case also demon¬ 
strates the necessity for, as well as the advisability of, carrying out 
multiple operations in successive stages when such procedures are 
indicated. 

Report of Case No. 14590. 

Mrs. J. K. S., aged thirty-nine years, weight 110 kilograms, 
entered the hospital December 14, 1921. 

Diagnosis: Umbilical and incisional hernia; uterine prolapse; 
varicose veins of both legs; hemorrhoids. 


HERNIA 


413 


hirst Operation: December 22,1921; lipectomy; repair of hernia; 
division of viscero-parietal adhesions; suspension of the uterus. 

Second Operation: January 11, 1922; perineorrhaphy; hemorrhoid¬ 
ectomy. 

Third Operation: January 20, 1922; double Trendelenburg 

ligation and excision of veins. 

Anesthesia: Local infiltration. 

History: Patient had undergone a gall-bladder operation eight 
years previously and an operation for the repair of an umbilical 
and incisional hernia two years before presenting herself for treat¬ 
ment. Her weight was 110 kilograms, blood-pressure 240 over 160. 
1 he urine contained a trace of albumin and hyaline casts. She was 
the mother of twelve children. 



Fig. 176.—Incisional hernia. Photograph of Case No. 14590 before operation. 


Physical examination (Fig. 176) showed a pendulous abdomen 
with a hernial sac containing practically all of the movable abdominal 
viscera. The uterus w r as prolapsed to the third degree and both 
limbs showed marked varicosities and an excessive amount of 
edema. 

The patient was placed in bed on medical treatment for eight 
days, when the abdomen was opened under local anesthesia as 
described in Chapter XIV. All the viscero-parietal adhesions were 
divided and the sac was found to contain stomach, large and small 
intestines and greater omentum. The upper incision, which was 50 
cm. in length, was carried down to the aponeuroses after making a 
subdermal infiltration. A subaponeurotic infiltration was then 




414 


SURGERY OF THE ABDOMINAL WALL 


carried out from the linea alba in the epigastrium to the anterior- 
superior spine on each side. A perfect negative pressure was 
obtained and the viscera were allowed to drop into the abdomen 



Fig. 177.—Incisional hernia. Photograph of Case No. 14590, during operation. 

bv force of gravity alone. A salt pad was placed over the hernial 
ring and the lower incision carried out without the introduction of 



Fig. 178.—Incisional hernia. Photograph of Case No. 14590, after operation. 

additional anesthesia. A large elliptical piece of fat and skin was 
removed. The upper abdominal wall was retracted vertically and 
extensive viscero-parietal adhesions were divided, freeing the 





HERNIA 


415 


pylorus and duodenum from the abdominal wall. The greater 
omentum was sutured over the denuded portion of the parietal 
peritoneum. The patient was then placed in the Trendelenburg 
position and the round ligaments attached to the anterior surface 
of the uterus, suspending in ante version. 

r lhe shaped incision was closed by overlapping the four 

rectangular flaps which were held in position by means of mattress 
sutures of chromicized catgut. Cigarette drains were placed in the 
angles of the incision. The closure was completed by means of 
“Figure-of-eight” silkworm-gut sutures. Primary healing followed. 
The patient lost weight constantly upon a restricted diet and the 
blood-pressure fell to 170 over 130. 

The second operation was done on January 11, 1922. The 
perineum was repaired under infiltration anesthesia (see Figs. 143 
and 144, page 350; Fig. 145, page 351; Fig. 158, page 374). The 
hemorrhoids were removed by the clamp and cautery after an 
infiltration block (see page 3G5). 

The third operation was performed nine days later and the 
varicose veins were ligated and excised under an infiltration de¬ 
scribed on page 313. 

The patient was discharged on February 7, eight weeks after 
entering the hospital, cured. Her total loss of weight while in the 
hospital was 50 pounds. The blood-pressure averaged 170 during 
the final weeks of her stay in the hospital and the albumin dis¬ 
appeared entirely from her urine. 

Note .—This patient vomited but once during the performance of 
these operations. The condition of the kidneys, the high blood- 
pressure, the excessive fat and the numerous surgical problems 
present, considering the outcome, would lend weight to our con¬ 
tention that such problems may be met in the manner described 
above or by the use of the principles which were followed in this 
case. Figs. 176, 177 and 178 show the patient before, during and 
after operation. 

Strangulated Hernia.— While all forms of hernia of the abdominal 
wall are amenable to the use of local anesthesia, the necessity for its 
use is urgent only in a comparatively small percentage of cases. 
In the great majority of hernia operations the general condition of 
the patient is good and the operation carries a low mortality under 
any form of anesthesia. Local anesthesia is recommended here more 
for the increased comfort, the lessened morbidity, the slightly low¬ 
ered risk, both immediate and remote, and the opportunity afforded 
for doing a more refined operation than when general anesthesia is 
used. In strangulated hernia many of these features assume more im¬ 
portance, and the factor of safety in the severe cases where delay has 
taken place stands out above all others. In many of these cases 


416 


SURGERY OF THE ABDOMINAL WALL 


the induction of general anesthesia alone may be sufficient to snuff 
out the spark of life that remains. Even the milder cases should 
have the benefit of every factor of safety, but unfortunately the 
extreme cases only are selected for local anesthesia in some of the 
clinics which are thought to represent the most advanced methods 
in use at this time. 

Every attention should be given to the general condition of 
these patients, gastric lavage for regurgitant vomiting being one of 
the most important items. It is difficult to reconcile the adminis¬ 
tration of a general anesthetic with the best surgical judgment in 
the case of a patient with regurgitant vomiting and all it implies, 
for an operation attempted as a last resort. It would seem that 
there could be no possible excuse for such a procedure with the 
expedient of local anesthesia at hand. 

The technic does not differ from that described for the various 
operations for simple hernia. Every condition to be met can be 
dealt with as well and many conditions can be handled with more 
facility than when general anesthesia is used. The stimulating 
effect of the solution at once improves the patient’s condition and 
local conditions are made more favorable for operations than when 
general anesthesia is used. The congested, engorged, heaving 
tissues so often met with in these cases when under general anes¬ 
thesia are very unlike the placid, quiet, blanched condition produced 
by the use of local anesthesia. In several instances the author has 
performed intestinal resection under the influence of local anesthesia 
when the use of general anesthesia even for the first stage of a two- 
stage operation would have been considered extremely hazardous. 
The life-saving expedient of emptying the bowel at operation 
through a trocar introduced at several different points along the 
tract may be carried out to almost any degree in patients in whom 
general anesthesia could not be continued sufficiently long to allow 
this to be done. (See page 469.) 

In multilocular hernise, or those having a number of compart¬ 
ments to the sac, it is often necessary to traumatize a great deal of 
tissue in freeing the different loops. Large umbilical hernke may 
contain as many as fifteen or twenty of these sacs. Now, provided 
one of the distal loops should become obstructed, the loops above 
this point will distend rapidly and we may find a large number of 
strangulated hernise, so to speak, in a single case. One is here 
confronted with a large number of obstructions at once and as it is 
often impossible to judge which one is the “key,” the only method 
of procedure is to free the coils as they present. This most 
tedious task may be carried out under local anesthesia without 
greatly reducing the patient’s resources, while under general 
anesthesia such a procedure in an advanced case would be extremely 


HERNIA 


417 


hazardous. After the ineision has been made and the neck of the 
sac injected, one has only to sit down and methodically free the 
adherent coils. An enterostomy in these cases leaves much to be 
desired at the second operation and should be avoided if possible. 
The following case will illustrate these points: 

Report of Case No. 7305. 

Mrs. C. D. E., female, aged fifty-four years, entered hospital 
March 20, 1914. 

Diagnosis: Strangulated umbilical hernia. Chronic myocarditis. 

Anesthesia: Local infiltration block. 

Operation: Reduction and repair. 

History: The patient weighed 125 kilograms. She entered the 
hospital with a strangulation of two days’ duration, in the sac of a 
recurrent umbilical hernia. Her pulse was weak and the patient 
was cyanotic. 

The tumor was the size of a basket ball and required an incision 
108 cm. in length to surround it. 360 cc of a 0.5 per cent novocain- 
adrenalin solution were introduced and the sac was opened. It was 
found to be multilocular and each compartment contained one or 
more adherent loops of the small or large bowel. As it was impos¬ 
sible to decide which was the first loop caught, and as every loop 
had become strangulated due to backing up of gas and fecal material, 
an attempt to free the constricted coils in logical order was made, 
the effect upon the patient being carefully noted as the work pro¬ 
ceeded. After working one and three-fourths hours the effect of the 
anesthetic wore off and the condition of the patient seemed to grow 
steadily worse. The addition of 90 cc of novocain-adrenalin 
solution made it possible to continue the dissection. It required 
four hours in all to complete the operation and although the patient 
was pulseless a part of the time, the pulse rate at the end of the 
operation was 140. A large amount of fluid was given intravenously 
and hypodermically. The patient made an uneventful recovery, 
going home by auto after five weeks. 

Strangulated or incarcerated femoral hernia may be treated under 
the usual technic and should intestinal resection become necessary, 
the abdomen may be opened from above by making a direct infiltra¬ 
tion. Simple strangulated femoral hernia may be operated upon 
with little more difficulty than is the case when strangulation is not 
present. 

Case No. 12249 is one of incarcerated femoral hernia and shows 
the application of local infiltration in the required surgical 
procedure. 


418 


SURGERY OF THE ABDOMINAL WALL 


Report of Case No. 12249. 

Mrs. W. M. N., aged fifty-five years, entered hospital August 26, 
1919. 

Diagnosis: Incarcerated femoral hernia. 

Operation: Reduction and repair. 

Anesthesia: Local infiltration. 

History: Six hours before operation patient had a severe attack 
of abdominal pain in the region of the left femoral canal at the site 
of a hernia which she had had for many years. The hernial tumor 
became greatly increased in size and at the time of operation was the 
size of a large grape fruit. 

Technic of Anesthesia: A local infiltration of a 0.7 per cent novo¬ 
cain-adrenalin solution—200 cc—was made. 

A transverse incision was made, the sac was opened and found to 
contain a large amount of omentum and two dark coils of small 
intestine. The omentum was removed after freeing adhesions, the 
neck of the sac enlarged and as the constriction was removed the 
dark intestine became pink and was returned to the abdomen. 

Undoubtedly the most potent reason for avoiding general anes¬ 
thesia in intestinal obstruction from any cause is the danger of 
inhaling regurgitated fecal material. This reason alone is sufficient 
to remove strangulated hernise from the realm of inhalation 
anesthesia for all time. 


CHAPTER XV. 


LOCAL ANESTHESIA IN SURGERY OF THE UPPER 

ABDOMEN. 


Ihe surgery of the following organs lying in this region will be 
discussed: stomach, duodenum, liver, gall-bladder, pancreas and 
spleen. 

Position of the Patient upon the Operating Table.—The reverse 
Trendelenburg position, with a tilting to the right in case the spleen 
or the greater curvature of the stomach is to be dealt with, and to 
the left when dealing with the gall-bladder, will often given one a 
most excellent opportunity for performing operations in the upper 
abdomen. The advantage to be gained by tilting of the table and 
the aid ol the force of gravity is not as great as that offered in the 
region below the umbilicus. However, even in this region one can, 
by placing the patient upon an incline and by carefully maintaining 
the duodenum, colon and stomach in a position of downward trac¬ 
tion, deal successfully with the pathology of the gall-bladder and 
ducts in a large percentage of cases. During the last five years the 
author has done over 90 per cent of these operations under local 
anesthesia. 

THE STOMACH. 

Operations upon the stomach for benign disease are most easily 
performed through a transverse incision across the recti muscles. 
It is the author’s custom to incise the linea alba and the mesial 
portion of one or both rectus muscles, retracting vertically the 
while until an exploration has been made. In these cases the round 
ligament of the liver should be blocked before the abdominal wall 
is incised and the incision may then be carried vertically upward 
at any point which may seem desirable. Operations upon the 
duodenum and pyloric region of the stomach should be preceded by 
the induction of anterior splanchnic anesthesia (Fig. 29, page 128). 
The splanchnic area may be exposed by gentle upward traction 
of the liver edge while the duodenum and pylorus are gently 
drawn downward, when a liberal supply of novocain-adrenalin is 
introduced beneath the peritoneum. The gastro-hepatic omentum 
should be infiltrated before being divided and it is well also to 
deposit some of the solution in the region of the larger vessels as 
they appear during dissection. 


420 


SURGERY OF THE UPPER ABDOMEN 


Pylorectomy, the Finney operation and the excision of ulcers 
may be carried out under this plan. 

Avoidance of Clamps.— In benign diseases the author has generally 
avoided the application of clamps to the stomach wall. Bleeding 
vessels should be caught in fine hemostats as the stomach wall is 
incised and by the use of these instruments the stomach wall is 
elevated, thus effectually controlling the same and preventing the 
escape of gastric contents. As soon as the stomach is opened all 
fluid within it may be removed by means of suction. 

Gastroenterostomy (Anterior).— Anterior gastroenterostomy re- 
cpiires the use of no anesthesia within the abdominal cavity, but 
does require the application of a surgical technic of a type which is 
compatible with local anesthesia. 

With the abdomen opened and a perfect negative pressure the 
colon may be carefully lifted out, traction being avoided, and the 
proximal end of the jejunum picked up. The jejunum should be 
identified by vision rather than by exploration, although one may 
in some instances be compelled to reach down and find it with the 
finger. This becomes necessary provided the patient is straining 
and forcing the small intestine into the field. However, with the 
establishment of good local anesthesia this contingency does not 
arise. In almost every instance one is able to see the jejunum 
and distal end of the duodenum before handling the small intestine 
at all. 

The following case will illustrate the benign effect of the applica¬ 
tion of local anesthesia for the relief of pyloric stenosis due to 
malignancy: 

Report of Case No. 9145. 

C. B. D., male, aged forty-seven years, entered the hospital 
July 8, 1916. There was great emaciation. 

Diagnosis: Cancer of the pylorus, with obstruction. 

Operation: Gastroenterostomy. Anterior. 

Anesthesia: Local infiltration. 

History: On July 9, 1916, the patient was operated upon and a 
diagnosis of cancer of the pylorus, with obstruction, was made. 
The tumor was large and fixed. 

Technic of Anesthesia: Local infiltration using 120 cc of a 0.5 of 
1 per cent novocain-adrenalin solution. 

Preliminary Medication: J- gr. pantopon and ytto- scopolamin. 

Operation: An infiltration was made across both recti, which 
were divided, and the abdomen opened under negative pressure. 
An exposure of the liver showed metastasis in this organ. The 
stomach tumor was fixed. The colon was gently lifted out and the 
proximal jejunum visualized. A point on the jejunum distal to 


THE STOMACH 


421 


the ligament of Treitz was defined by the means of forceps and an 
anterior gastroenterostomy performed, as it seemed impracticable 
to attempt to dislodge the adherent stomach. No intraperitoneal 
anesthesia was employed. 

At the completion of the operation the patient’s pulse was 72. 
He took fluids by mouth immediately and sat up within a few hours. 
The operation was entirely painless. 

Gastroenterostomy (Posterior). — Posterior gastroenterostomy 
requires only anesthesia of the abdominal wall, plus careful manip¬ 
ulation and the avoidance of traction. The jejunum is identified 
by the manner mentioned under the description of anterior gastro¬ 
enterostomy. The mesocolon is incised and the opening gently 
spread, the point at which the stomach is to be opened having 
been previously identified by means of a clip icliich has been placed 
at the lower border of the stomach, anterior to the gastrocolic omentum. 
As soon as the rent is made in the colonic mesentery an ap¬ 
propriate point upon the stomach wall is identified by means 
of this clip, which gently forces the lower border of the stomach 
into view. The stomach wall is now picked up by two clips and 
by means of gentle traction, aided by a few deep inspirations on 
the part of the patient, may usually be raised well above the ab¬ 
dominal wall. After the placing of sponges no further traction will 
be found necessary and the use of clamps is avoided. Incisions 
in the stomach or intestine are each preceded by the making of a 
puncture through all coats. A scissors point is then introduced 
and the requisite incision completed. In this manner added 
traction is avoided. 

It is well to suture the colonic mesentery to the stomach wall 
before anastomosis is begun, for to do so after the anastomosis is 
completed may necessitate traction. The introduction of pon¬ 
derous packs should be avoided. It is especially desirable to avoid 
the introduction of too long or too heavy a pack beneath the point 
of anastomosis, as the removal of such a pack may cause the patient 
some distress. 

The following case will illustrate the excision of ulcer with pylo¬ 
roplasty: 

Report of Case No. 13079. 

R. C. F., aged fifty-eight years, referred by Dr. T. A. Peppard, 
entered the hospital March 20, 1920. 

Diagnosis: Chronic gastric ulcer (prepyloric). 

Operation: Resection of ulcer; pyloroplasty. 

Technic of Anesthesia: Local anesthesia, 120 cc of a 0.7 of 1 per 
cent novocain-adrenalin solution, with a “T infiltration of the 
abdominal wall. 


422 


SURGERY OF THE UPPER ABDOMEN 


Both recti were divided with a vertical incision up the midline. 
The abdomen was opened with perfect negative pressure. The 
gastric side of the pylorus presented an indurated mass the size 
of a large olive, extending along the lesser curvature. A plastic 
resection was made without the use of clamps, closure being made 
with chromic gut. The abdomen was closed without drainage. 

The next case will illustrate the satisfactory manner in which 
old and debilitated individuals may be operated upon by the use 
of local anesthesia. 


Report of Case No: 14121. 

A. J. S., aged eighty-two years, entered the hospital January 
29, 1921. 

Diagnosis: Duodenal ulcer with threatened perforation. 

Operation: Posterior gastroenterostomy. 

Anesthesia: Local infiltration. 

History: Patient had had stomach trouble for two years and 
had had about fifty attacks of severe pain, with an acute exacer¬ 
bation of the trouble two days previous to his entry into the 
hospital. The upper abdomen was found to be extremely tender 
and rigid and his stools showed microscopic blood. He passed 
630 cc of urine in twenty-four hours, with a specific gravity of 1026. 
The urine showed albumin, hyaline and granular casts. The 
leukocyte count was 6600. Barium roentgen rays showed a filling 
defect in the duodenum. A preoperative diagnosis of duodenal 
ulcer with threatened perforation was made. His condition 
became steadily worse and four days after his entry into the hospital 
the abdomen was opened. 

Technic of Anesthesia: 90 cc of a 0.7 of 1 per cent novocain- 
adrenalin solution was infiltrated into the abdominal wall. 

An “L” incision was made, dividing the right rectus muscle, 
and the abdomen opened with a perfect negative pressure. The 
gall-bladder appeared normal but there was a mass in the region 
of the pylorus, apparently on the duodenal side. The region 
about the ulcer was adherent to the parietal peritoneum and the 
adhesions, being recent, were easily separated. A posterior gastro¬ 
enterostomy was performed after the method of Moynihan except 
that the clamps were not used. The ulcer area was turned in with 
chromic catgut stitches and a piece of the greater omentum placed 
over it. The patient was immediately placed on ulcer management. 
He did not vomit but on the fourth day developed hypostatic 
pneumonia. He was placed in a sitting posture, and sat up in 
a chair on the sixteenth day. 


THE STOMACH 


423 


Ulcers.—Perforated Gastric and Duodenal Ulcers; Acute and 
Chronic.—The surgical treatment of acute perforated gastric or 
duodenal ulcer demands the infiltration of the abdominal wall, a 
liberal incision, and in a certain percentage of cases, anterior splanch¬ 
nic anesthesia. The author has not operated upon any of these 
cases without the preliminary use of morphine, as in most cases 
the pain has been so great that the patient was well narcotized 
before entering the operating room. 

The perforated ulcer may be attacked, provided proper exposure 
is obtained, without distress to the patient, and may be dealt with 
as the condition requires. In acute perforations gastroenterostomy 
has been avoided and the condition treated by cauterization , 
excision, or simple closure of the ulcer. All cases encountered during 
the past fifteen years have been done under local anesthesia. 

The following interesting observation has been made in a number 
of cases. Even when morphine failed to control the pain before 
operation the careful blocking of the abdominal wall resulted in 
great reduction of the pain, and always in material relief from 
muscular spasm. 

The following case offers a splendid example of this point: 

Report of Case No. 14526. 

M. B. C., aged sixty-three years, entered hospital October 17, 
1921, at 5 p.m. 

Diagnosis: Perforated duodenal ulcer. 

Operation: Excision and suture. 

History: This patient had had symptoms for twenty-five years. 
The present attack began at noon. 

Technic of Anesthesia: Novocain-adrenalin 1 per cent by infil¬ 
tration of 150 cc solution. 

Operation at 6 p.m.: An “L” incision dividing the right rectus 
was made. The patient had had gr. \ morphine sulphate without 
relief and the parietes were extremely rigid. As soon as the infil¬ 
tration was made the pain subsided and rigidity decreased markedly. 
The abdomen was opened with a negative pressure, the duodenum 
was separated from the liver and an opening 0.5 cm. in diameter 
was exposed. The ulcer was excised, the edges cauterized and a 
plastic closure with catgut was carried out. 1 )rainage was employed 
and the patient made an uneventful recovery. 

The surgical treatment of chronic perforated ulcers demands an 
anterior splanchnic anesthesia in addition to an infiltration of the 
abdominal wall. 

Case No. 11791 illustrates the means by which chronic perforated 
gastric ulcer may be handled under local anesthesia. 


424 


SURGERY OF THE UPPER ABDOMEN 


Report of Case No. 11791. 

E. W. D., aged sixty-eight years, referred by Dr. E. L. Gardner, 
entered the hospital November 7, 1918. 

Diagnosis: Perforated gastric nicer with possible malignancy. 
(See Roentgenogram, Fig. 179.) 



Fig. 179.— Gastric ulcer (chronic, perforated). Roentgenograph of Case No. 11791. 

Operation: Excision of the ulcer-bearing area. 

Anesthesia: Local infiltration and anterior splanchnic. 

History: Patient weighed 45 kilograms at the time she entered the 
hospital, while her normal weight was 55 kilograms. She had had 
gastric symptoms for two years and five weeks before entering 
the hospital she had experienced a sudden sharp pain in the epigas¬ 
trium, followed by nausea and vomiting. She remained in bed a 
few days and a considerable soreness continued. 










THE STOMACH 


425 


Technic of Anesthesia: Local infiltration, 150 cc of a 0.5 of 1 
per cent novocain-adrenalin solution being used. 

An infiltration was made across the left rectus, with a vertical 
limb. The left rectus was then divided and the abdomen opened 
under a negative pressure. The pylorus appeared normal. 
Anterior splanchnic anesthesia was established and the lesser omen¬ 
tum divided. In the lesser curvature a mass the size of a lemon 
could be felt. The abdominal wall was retracted verticallv, salt 
packs were inserted and the gastric wall was elevated by means 
of tacking forceps. An incision was made in the anterior wall of 
the stomach and this organ was carefully emptied by suction. 
The ulcer was excised with scissors down to the region of the pan¬ 
creas to which it was attached bv inflammatory adhesions. 
perforating point connected directly with the surface of the pancreas. 
The mass was easily separated without hemorrhage and without 
painful sensation to the patient. All bleeding points in the severed 
stomach wall were ligated and the edges united by two layers of 
chromic gut. A cigarette drain was inserted into the lesser peri¬ 
toneal cavity and the abdomen closed in layers. At the beginning 
of the operation the patient’s pulse was 80, and at the close, 70. 
There was no change in blood-pressure or color. She was dis¬ 
charged fifteen days later. 

Patients in desperate condition from perforated ulcers may 
sometimes be operated upon under this system to great advantage. 
See Case No. 13058, which follows: 

Report of Case No. 13058. 

C. J., aged sixty years, entered the hospital December 3, 1920. 

Diagnosis: Perforated duodenal ulcer. 

Operation: Pylorectomy. 

Anesthesia: Local infiltration and anterior splanchnic. 

History: The patient had been on an ulcer regime for two 
weeks. On December 6, he was seized with a sudden severe pain 
at 1 a.m., and a hypodermoclvsis was begun beneath the pectoral 
muscles. A diagnosis of a perforating ulcer of the duodenum was 
made, and he was operated upon, a resection being done. 

A transverse infiltration was made across the upper abdomen 
and a vertical limb was added to this. One-half hour before 
the operation he had been given a hypodermic of morphine gr. J, 
without relief of pain. He was cyanotic and his pulse was 160. 
Immediately upon blocking the abdominal wall the muscles became 
relaxed to some degree and he volunteered the information that 
the pain had been much relieved. The abdomen was opened with¬ 
out extrusion of the viscera. 


426 


SURGERY OF THE UPPER ABDOMEN 


Examination showed an angry-looking, thickened mass in the 
duodenum which presented a perforation on the anterior surface. 
An attempt was made to close the perforation, but the tissues were 
so friable that the sutures cut through. It seemed that only by 
a resection could the indications be met, although the patient’s 
condition was such that this course seemed hardly justified. 
Anterior splanchnic anesthesia was established. The duodenum 
was partially mobilized and a “V”-shaped piece, including the 
tumor, was excised between clamps. A large stomach tube was 
then passed through the esophagus and made to emerge through 
the pylorus. From there it was introduced into the jejunum a 
distance of 15 cm. It was but a moment’s work to introduce a 
continuous catgut suture along the severed edge of the duodenum, 
reestablishing a canal. The abdomen was then hastily closed with 
drainage. 

For a period of fourteen hours following the operation the patient’s 
pulse could not be felt at the wrist. 250 cc of hot water were 
introduced into the jejunum every three hours. He made a slow 
but uninterrupted recovery. 

He was once more placed on the ulcer management and remained 
fairly well for six months. However, he began to have recurrent 
attacks of vomiting and an examination fourteen months after 
the operation showed food retention, hyperchlorhydria and stenosis 
at the point of the duodenal resection. A pneumoperitoneum 
showed extensive visceroparietal adhesions between the umbilicus 
and the ensiform. 

On January 11, 1922, the patient reentered the hospital. 

Diagnosis: Recurrent duodenal ulcer; duodenal stenosis, incisional 
hernia; visceroparietal adhesions and left inguinal hernia. 

Operation: Posterior gastroenterostomy; division of adhesions; 
repair of incisional hernia. 

Technic of Anesthesia: Infiltration block and anterior splanchnic. 

A circumferential infiltration block was made about the site of 
the former incision and the abdomen opened with negative pressure. 
The abdominal wall was retracted vertically, and the greater 
omentum, transverse colon and anterior surface of the pylorus 
were separated from the parietal peritoneum without causing 
hemorrhage. The duodenum was examined and found to con¬ 
tain a hard mass, causing constriction. An anterior splanchnic 
anesthesia was established and a posterior gastroenterostomy 
performed after the method of Moynihan. The abdominal parietes 
presented a defect approximately 10 cm. long. The intercostal 
nerves were blocked in the nipple line and a flap of skin and sub¬ 
cutaneous tissue raised, after which a reversed pedicle flap of 
pectoral fascia, 18 cm. long and 12 cm. wide, was dissected down- 


THE STOMACH 


427 


ward from the thoracic wall and sutured to the lower edge of the 
abdominal hernia. (See page 407.) The patient’s pulse at the 
close of the operation was 80. He went through his convalescence 
without nausea, vomiting or thirst, but developed a septic bron¬ 
chitis about the fourth day, which annoyed him for three or four 
days. 

Twelve days after the performance of the gastroenterostomy 
a left inguinal hernia was repaired under local anesthesia after 
the method of Torek. 

Sleeve Resection. —Sleeve resection for hour-glass stomach re¬ 
quires infiltration of the abdominal wall, and anterior splanchnic 
anesthesia. The following case will illustrate the technic of this 
procedure: 


Report of Case No. 9216. 


F. S. C., aged sixty-three years, entered the hospital May 16, 
1916. 

Diagnosis: Chronic gastric ulcer with an hour-glass contraction. 

Operation: Sleeve resection. 

Anesthesia: Local infiltration and anterior splanchnic. 

History: The patient weighed 50 kilograms, while her normal 
weight was 55 kilograms. For a number of years the patient had 
had distress two or three hours after each meal, which was relieved 
by food and soda. This condition had continued for ten years, 
and seemed to be worse in the spring and fall. A year before 
entering the hospital she had had a severe hemorrhage from the 
stomach. She was frequently compelled to get up at night to 
take food and soda for the pain. Roentgen rays of the stomach 
showed an hour-glass contraction. 

Preliminary Medication: Morphin gr. J and scopolamin gr. 

_A_ 

2 ° o • 

Technic of Anesthesia: Local infiltration block. 

A transverse infiltration was made across the upper abdomen, 
and both recti divided. This was followed by a vertical infiltration, 
and an incision from the midline to the ensiform. A perfect 
negative pressure was obtained. The stomach presented a stricture 
at the midpoint with a thickened mass in the lesser curvature. 
The stomach was freed over its central area after injecting the 
lesser omentum with novocain-adrenalin solution. Clamps were 
placed directly on either side of the mass, extending from the 
greater to the lesser curvature. A sleeve resection was made and 
the stomach reconstructed by the use of chromic catgut sutures, 
the shoemaker stitch being used. The abdomen was closed with¬ 
out drainage. 


428 


SURGERY OF THE UPPER ABDOMEN 


Note .—The small intestine was not seen at any time during the 
operation. At the close of the operation the patient’s pulse was 
76. There was no postoperative nausea or vomiting, and she 
made an uneventful recovery. 

The accompanying chart (Fig. 180) shows the pulse rate before, 
during and after the operation, covering in all a period of one 
week. 



Fig. 180.—Hour-glass stomach. Postoperative chart of Case No. 9210 following 

“sleeve” resection. 


Neoplasms (Malignant).—Resection for Carcinoma. —Gastric re¬ 
section for carcinoma is possible under infiltration of the ab¬ 
dominal wall, combined with anterior or posterior splanchnic 
anesthesia. 

The welfare of these patients demands the use of every artifice 
known to surgery in order to safeguard them against the dangers 
connected with such an extensive procedure as gastric resection. 

The incision should be ample and in some cases we have not 
hesitated to divide two or three ribs and draw back a flap at the 
costal border in order to avoid making too much traction upon the 
stomach wall. The splanchnic anesthesia may be reinforced at 
any time when a vessel is encountered, although the stomach wall 
itself need not be infiltrated. 

The following case will illustrate the application of local anes¬ 
thesia to surgery of malignant disease of the stomach, with the 
combined use of abdominal infiltration and anterior splanchnic 
anesthesia: 











































































































THE STOMACH 


429 


Report of Case No. 9214. 

1). E., aged sixty years, entered the hospital August 17, 1916. 

Diagnosis: Cancer of the greater curvature of the stomach. 

Operation: Gastric resection. 

7 echnic of Anesthesia: Local infiltration and anterior splanchnic. 
A transverse infiltration across both recti was made, using 150 cc 
of a 0.5 per cent novocain-adrenalin solution. 

The abdomen was opened with perfect negative pressure and 
a large tumor in the greater curvature presented in the incision. 
The lesser omentum was infiltrated with novocain-adrenalin 
solution and divided. After a thorough examination of the liver, 
which revealed no signs of metastasis, it was decided that the case 
was probably operable. The retroperitoneal space, which was 
exposed after dividing the gastrohepatic omentum, was carefully 
infiltrated with novocain-adrenalin solution. The duodenum 
was then divided between clamps and the stomach turned out to 
the left. This was entirely painless. The stomach was divided 
between clamps beyond Hartmann’s line. This maneuver also 
was painless. The jejunum was anastomosed to the lower portion 
of the gastric incision, the remainder of which was closed with 
linen. The patient’s pulse was 74 at the completion of the operation, 
with no change in his color or general condition, except that he 
was tired. The operation required one hour and thirty minutes. 
His recovery was uneventful. 

The next case illustrates how the mobilization of the chest wall 
facilitates extensive gastric resections in desperate cases. 


Report of Case No. 13658. 

J. M., aged fifty-two years, entered hospital March 2, 1920. 

Diagnosis: Carcinoma of stomach. 

Operation: Gastric resection. 

History: The patient has had gastric symptoms since September, 
1919. There are no obstructive symptoms. Examination shows 
a large mass at the pyloric end of the stomach, undoubtedly malig¬ 
nant in nature. 

Technic of Anesthesia: Intercostal block of left side in nipple 
line from the fifth rib downward. 

Transverse infiltration across the recti with a vertical limb in 
the midline. 

Operation: T-incision. Abdomen opened with a perfect negative 
pressure, only stomach and colon being visible. The liver showed 
no involvement. The tumor was freely movable and occupied 


430 


SURGERY OF THE UPPER ABDOMEN 


the mesial half of the stomach, extending well up on the lesser 
curvature. The stomach lay extremely high and the growth 
extended well under the costal margin. A skin flap was raised 
and several ribs were divided near the nipple line, thus allowing 
the chest wall to be retracted and giving an excellent exposure. 
An anterior splanchnic anesthesia was established, the lesser 
omentum being divided and ligated. The pylorus was then divided 
between clamps and the stomach turned to the left, all retaining 
bands being infiltrated before division. This procedure was 
entirely painless. Resection was then made without the use of 
clamps, the bleeding vessels being picked up as they appeared. 
The jejunum was located. The Polya operation was then per¬ 
formed. The abdomen was closed without drainage. The patient 
went on smoothly for ten days, at which time he began to have pain 
in his upper abdomen, progressive weakness and sank rapidly, 
dying on the twelfth day. 

Autopsy showed a necrosis of the cardiac end of suture line with 
gangrene of the wall of the stomach over an area approximately 
the size of a silver dollar. 

Note .—This patient went through his operation, which was very 
extensive, without shock or depression, and under the technic 
employed the anesthesia was ideal. However, possibly some error 
was made in the technic whereby the gastric blood supply was not 
properly conserved. No local infiltration was made in the region 
where the necrosis appeared so that the anesthesia could not have 
been a causative factor in the production of the gangrene. 

Hypertrophic Pyloric Stenosis.— There is no field in the whole 
domain of surgery in which the advantages of local over general 
anesthesia are so definite and clear cut as in the surgical treatment 
of this debilitating condition. By the judicious use of local anes¬ 
thesia and careful attention to the technical details the operation 
for the relief of this condition is brought close to the border-line 
between major and minor surgery. These little babies who usually 
weigh less than one-half the amount they did at birth are extremely 
hazardous risks, and the administration of general anesthesia is 
sufficient, in a certain percentage of cases, to sever the remaining 
thread of life. Provided the obstruction can be overcome with¬ 
out adding too greatly to the depression already present, or with¬ 
out increasing the depletion of other vital forces to too great an 
extent, the opportunity for spectacular results is amazing. 

Local anesthesia in these cases, in order to be successfully carried 
out, must be fortified by many other adjuncts. The following 
plan, developed in the author’s clinic, will be given somewhat in 
detail, as it is believed that the difference between success and 


THE STOMACH 


431 


failui e in handling patients of this type is intimately associated 
xv attention to a number of more or less important details. 

Before the beginning of the operation the child’s stomach should 
be emptied by the passage of a tube, and as much fluid and gas as 
possible expressed by making firm pressure upon the abdominal 
wall. 1 he patient should be restrained by the method shown in 
higs. 181 and 182. We have found the following arrangement of 



Fig. 181 .—Method of restraining children during operation. 


the table most satisfactory. A small arm-table is placed at right 
angles to the rectangular operating table and the child is laid upon 
it with its body encased in a thick pad of sterile cotton. The feet 
are anchored to the opposite side of the operating table and the 
anesthetist, who is seated at the child’s head, grasps the arms in 
her hands and is thus prepared to make traction upon the child’s 
body whenever necessary. The abdominal wall is sterilized and 































SURGERY OF THE UPPER ABDOMEN 


A 99 
‘iOl 

the sterile drapes are applied, the operating table being used as 
an instrument table. The surgeon sits at the right of the child 
and his assistant at the left (Fig. 185). But 15 to 30 cc of solution 
are required to anesthetize the abdominal wall (Fig. 184). Fig. 



Fig. 182. —Hypertrophic pyloric stenosis. Restraint of child. 



Fig. 183. —Hypertrophic pyloric stenosis. Ensemble pneumatic injector psycho- 
anesthetist, sterile towel guard and instrument table, child ready for operation. 


185 shows the abdominal field isolated by sterile drapes, the position 
of the psycho-anesthetist and the pneumatic injector separated 
from the sterile field by means of a sterile towel which is attached 













THE STOMACH 


433 


to the towel rack. A sufficient amount of solution should be used 
to insure the establishment of absolute anesthesia. The abdominal 



Fig. 184.—Hypertrophic pyloric stenosis. Anesthesia technic; infiltration of 

abdominal wall. 



Fig. 185.—Hypertrophic pyloric stenosis. Photograph, ensemble, surgeon, assistant 

and psycho-anesthetist. 


wall should be elevated while the incision is being made (Fig. 
also Fig. 212, page 490). 



28 









434 


SURGERY OF THE UPPER ABDOMEN 


It is important to make the incision at about the level of the 
lower border of the liver. We prefer the transverse incision, which 
if made at this level and without pain to the patient, obviates the 
necessity of combating coils of small intestine during any stage 
of the operation. 



Fig. 186. —Hypertrophic pyloric stenosis. Photograph of skin elevation 

during incision. 


As soon as the abdomen is opened, one may, by carefully retract¬ 
ing the liver’s edge, visualize the hypertrophied pylorus, provided 
the stomach, which is always thick-walled and large, has previously 



Fig. 187.—Hypertrophic pyloric stenosis. Pylorus delivered. 


been completely emptied. Should the stomach obscure the view 
of the pylorus it may be gently retracted toward the left by means 
of a small retractor covered by a piece of gauze. As soon as the 
pylorus is visualized it may be grasped with a pair of delicate 
intestinal forceps (Fig. 26, page 110) and elevated into the incision 







THE STOMACH 


435 


in such a manner as to form a barrier to the extrusion of the intestines 
should the child strain during the remainder of the operation. 
(Fig. .187.) The delivery of the pylorus is made b} r means of deli¬ 
cate forceps which are preferable to the use of one’s fingers. The 
latter demand more room and a larger incision, and are more apt to 
cause the child distress. While the assistant steadies the pylorus, 



Fig. 188. —Hypertrophic pyloric stenosis. Ranmistedt’s operation. 

Insert shows line of incision. 


the surgeon may carefully perform the llammstedt operation 
(Fig. 188) under the most favorable conditions, i. e., the “silent” 
field. Just before returning the pylorus to the abdomen a fine 
suture may be introduced into the upper flap of the divided 
pyloric ring, and, after its return, the needle carrying the suture 
may be passed through a tab of omentum, which may thus be 
anchored over the pyloric incision. (Fig. 189.) We have, in 








436 


SURGERY OF THE UPPER ABDOMEN 


repeated instances, performed these operations without the child 
crying or making any expulsive effort throughout the whole pro¬ 
cedure. 



Fig. 189. —Hypertrophic pyloric stenosis. Rammstedt’s operation, omental graft 

in place. Insert : Sectional view of same. 


Case Reports Nos. 13831 and 11746 show the manner in which 
hypertrophic stenosis in infants may be treated surgically under 
local anesthesia. 


Report of Case No. 13831. 

B. S. M., aged three weeks, entered the hospital June 4, 1920. 
Diagnosis: Hypertrophic pyloric stenosis. 

Operation: Rammstedt pyloric incision. 

Anesthesia: Local infiltration. 












THE STOMACH 


437 


History: The patient had had regurgitant vomiting since birth, 
at which time he weighed 3600 gm. At the time he entered 
the hospital he weighed but 1800 gm. A diagnosis of congenital 
hypertrophic pyloric stenosis was made. 

Technic of Anesthesia: Local infiltration of abdominal wall. 

The Rammstedt operation was performed under local anesthesia. 
Just before opening the abdomen the stomach was emptied by 
passing a tube through the esophagus and making pressure upon 
the abdominal wall. 20 cc of a 0.7 of 1 percent novocain-adrenalin 
solution were used. A transverse infiltration was made (see Fig. 
184, page 433) and the right rectus divided. The incision lay 
just above the edge of the liver. The liver was gently retracted 
and the pylorus was seen and delivered by means of rubber-tipped 
thumb forceps. The Rammstedt operation was done. One suture 
held a piece of omentum over the pyloric incision and 180 cc of 
normal saline solution were injected into the peritoneal cavity 
before closing the incision. 

The baby began taking mother’s milk at once, and vomited but 
once, four days later. He made an uneventful recovery and was 

’ t/ 

discharged from the hospital four days after the operation. 

Note .—This patient was cyanotic at the time of the operation. 
He was extremely emaciated, and in the judgment of the author 
the worst risk he has had in this class of cases. 


Report of Case No. 11746. 

G. M., aged three weeks, entered hospital October 7, 1918, when 
weight was 1800 gm. 

Diagnosis: Hypertrophic pyloric stenosis. 

Operation: Rammstedt’s operation. (Pyloric incision.) 

Anesthesia: Local infiltration. 

History: Baby commenced vomiting when ten days old. '\ omit- 
ing has been persistent. Patient has lost 1300 gm. in weight. 

Technic of Anesthesia: 30 cc of 0.5 per cent novocain-adrenalin 
solution were injected transversely across the upper abdomen. 
(Fig. 184, page 433.) 

The patient was carefully wrapped in cotton and the restraint 
applied (Fig. 181, page 431). Iodine preparation of the skin fol¬ 
lowed. The incision was made between towel pins and the child 
did not cry. The stomach was emptied by the passage of a tube 
just before the abdomen was opened. The pylorus showed a 
marked hypertrophy as it was brought up with the long intestinal 
rubber-tipped forceps. The pyloric muscle was divided and the 
omentum was tacked over the mucosa with one fine catgut stitch. 
The abdomen was closed and the child made an uneventful recovery. 


438 


SURGERY OF THE UPPER ABDOMEN 


THE LIVER. 

r. 

Cysts, Abscess and Rupture.— The liver tissue may be cut or 
sutured without pain to the patient, and one may therefore per¬ 
form any operation upon this organ under local anesthesia, pro¬ 
vided the tissues can be visualized. 

The author’s experience in operating upon the liver under local 
anesthesia is confined to cases of liver abscess and rupture of the 
liver. 

Cysts.—Cysts may be excised or incised without additional 
anesthesia after the abdomen has been opened, provided traction 
on the liver has been avoided—otherwise anterior splanchnic 
anesthesia will be demanded. 

Abscess.—Abscesses may be drained with facility under this 
form of anesthesia, and the technic described above should be 
adequate, as it details the method of exposing this organ. 

Rupture.—Rupture of the liver presents a condition which should, 
when it is possible, be treated by the use of local anesthesia. The 
following case will illustrate this point: 


Report of Case No. 12402. 

C. J., aged nine years, entered hospital November 5, 1919, at 
11 p.m., giving the following history: 

Eleven hours previously the patient was struck by an auto and 
thrown to the ground. When seen by Dr. T. J. Movnihan, who 
referred the case for operation, the boy was in a dazed condition, 
but showed no abrasions upon the body. He was placed in bed 
and left with an attendant, and eight hours later, when the doctor 
was hurriedly summoned, was found to be in serious condition. 
He was sent to the hospital and the author was called to see him 
in consultation. 

The child at this time showed rapid and shallow respiration. 
He was extremely pale and unconscious. Plis pupils were dilated; 
the pulse imperceptible and the abdomen was distended and dull 
in both flanks. The patient was ordered at once to the operating 
room, and as the woman who had been driving the auto by which 
the boy was struck volunteered to act as donor, 400 cc of blood 
were withdrawn as rapidly as possible. 

The condition of the boy was so desperate that an assistant 
reported to the operating room that there was no necessity of bring¬ 
ing the boy up, as he would be dead before arriving there. Not¬ 
withstanding the fact that two hours previously the boy’s pulse 
was 120 to 130, when he entered the operating room he was appar¬ 
ently breathing his last and the transfusion of citrated blood was 
begun (without previous grouping). While his associates trans- 


THE LIVER 


439 


fused the boy, the author began infiltrating the abdominal wall 
^\ith O.o per cent novocain-adrenalin solution along the midline. 
Ihe transfusion and infiltration began simultaneously and within 
three minutes the child s pupils contracted rapidly and the pulse 
soon became perceptible. A 15 cm. midline incision was made 
and a large quantity of fresh blood escaped from the abdominal 
cavity. 1 he liver was inspected and seemed normal, although 
shrunken and pale. The intestinal tract and spleen were carefully 
gone over and no lesion demonstrated. It was therefore necessary 
to dry out practically the peritoneal cavity, as it was apparent 
that the child was still bleeding, and finally fresh blood could be 
seen welling up through the foramen of Winslow. The gastro- 
hepatic omentum was quickly opened and the subhepatic fossa 
sponged out, when an examination showed the liver ruptured pos¬ 
teriorly and separated from its normal attachments. The bleeding 
area was quickly packed with gauze. The peritoneal cavity was 
filled with physiological saline solution and closed. A rubber dam 
was placed about the packs isolating them from the raw surfaces. 

At the close of the operation the boy’s pulse was plainly per¬ 
ceptible with a rate of 140. lie was conscious, was placed in bed 
in the Trendelenburg position and given morphine sulphate, gr. J. 
He was in the operating room two hours. Two hours after the 
completion of the operation the pulse once more became imper¬ 
ceptible, the child complained of air-hunger and death seemed 


imminent. The transfusion was repeated, 300 cc of citrated 

blood being given. Following this the recovery of the child was 

uneventful. He remained in the hospital three weeks, most of 

which time was occupied in efforts to extract the gauze from the 

abdominal cavity. 

«/ 


Note .—This child was given 120 cc of 0.5 per cent novocain- 
adrenalin solution before the circulation had received an appre¬ 
ciable amount of the citrated blood. 

It will be noted that immediately after the administration of 
the anesthetic solution a marked change in the child’s condition 
supervened. This probably was due largely to the action of 
the adrenalin. However, in a number of similar instances this 
transformation has been duplicated and it is believed that novo¬ 
cain also is to be considered more or less of a stimulant under such 
conditions. Unfortunately, however, the stimulating effect is not, 
as a rule, maintained over any considerable length of time. While 
it seems probable that the adrenalin may be credited with a 
marked effect upon the recuperative power in individuals who 
are depleted, the conviction is not complete that its intravenous 
administration in physiological salt solution has produced the spec¬ 
tacular results which have followed the use of the novocain- 
adrenalin combination. 


440 


SURGERY OF THE UPPER ABDOMEN 


GALL-BLADDER AND DUCTS. 

The position of the patient on the table is a very important 
adjunct to the success of gall-bladder surgery under local anesthesia 
and the reverse Trendelenburg should be established before the 
anesthesia is started. 

The incisions which give the best exposure of the gall-bladder 
and ducts are the diagonal trans-rectus incision of Kocher or the 
transverse incision of Mavlard combined, when necessary, with 
a vertical incision at or near the midline. (See page 392.) 



Fig. 190.—Gall-bladder. Anesthesia technic; subdermal infiltration of abdominal 

wall. F, wheal for deep infiltration block. 


Technic of Anesthesia.—The incision is preceded by an infil¬ 
tration of the abdominal wall, special care being taken to deposit 
a liberal amount of solution into the region of the round ligament 
of the liver. This is done by introducing the needle through the 
linea alba in the midline, high up. A secondary infiltration block 
is made along the costal border (Fig. 190), in order to prevent pain 
in this region when retraction is used after the abdomen has been 





GALL-BLADDER AND DUCTS 


441 


opened. 1 he height of the transverse incision should be governed, 
to some extent, by the position of the lower border of the liver. 

Opening Abdominal Cavity.—As is the rule when making other 
abdominal incisions, the abdominal wall is retracted vertically while 
being incised (see Fig. 212, page 490), and every effort is made 
to enter the abdomen without the patient’s knowledge, or rather 
without the abdominal muscles knowing of the intrusion. In 
this manner a combative action on the part of the muscles is avoided. 
Every effort is made to obtain the much desired negative pressure. 
Success will give one the opportunity of making an examination 
of all the organs in this region and they may be seen lying and 
even functioning, normally or abnormally, as the case may be. 

Cholecystostomy.—Simple drainage of the gall-bladder under 
local anesthesia offers no special difficulty and may be carried out 
under anesthesia of the abdominal wall onlv. However, if one 
is to combine with cholecystostomy a complete exploration of the 
ducts and an examination of the pancreas, the operation offers 
considerable difficulty if it is to be performed under local anesthe¬ 
sia exclusively. The operation of cholecystectomy has been found 
much less trying under this form of anesthesia than that of chole¬ 
cystostomy when the latter is combined with complete exploration 
of the ducts. The exposure which is so desirable in working upon 
the ducts is more difficult to obtain before the freeing of the gall¬ 
bladder has been accomplished. After freeing the gall-bladder 
the exploration of the ducts becomes comparatively more simple. 
One may, however, by placing a gauze pad over the gall-bladder 
and lower surface of the liver, carefully retract these organs up¬ 
ward; then by retracting the stomach and duodenum downward 
one may visualize the ducts and palpate them after the estab¬ 
lishment of anterior splanchnic anesthesia. 

Sensation of the Gall-bladder.—The gall-bladder which is not 
acutel\ r inflamed is not tender, provided traction is avoided. There¬ 
fore, aspiration of the gall-bladder, suture of its wall, the removal 
of gall stones which lie freely within its cavity and the placing of 
drainage tubes may all be accomplished without pain if, as stated 
above, traction is avoided. Any attempt, however, to manipulate 
the acutely inflamed and distended gall-bladder will be apt to 
bring forth strenuous complaint on the part of the patient. 

Cholecystectomy.—The author has performed cholecystectomy 
in approximately 90 per cent of gall-bladder cases during the 
last ten y r ears and most of these have been done exclusively" with 
local anesthesia. The technic which he has found most satis¬ 
factory" will be described. 

Exposure.— After removal of the gall-bladder has been decided 
upon, three long narrow dry gauze sponges are carefully intro- 


442 


SURGERY OF THE UPPER ABDOMEN 


duced, the introduction of each being followed by the placing of 
a wire spring retractor. (See Fig. 12, page 99.) One of the gauze 
sponges is placed against the upper surface of the duodenum and 
transverse colon and the long loop of the retractor forces this 
organ downward toward the pubes. Morris’s pouch is likewise 
packed and a retractor of the same type forces the colon out of 
the field and to the right. A third pack and retractor forces the 
stomach and pylorus to the left. If collapsible, the gall-bladder 
fundus is now grasped by a pair of noncutting artery forceps. 



Fig. 191. —Gall-bladder. Cholecystectomy. Anesthesia technic; gall-bladder 
“blowing off.’’ Gauze packs omitted for purpose of clarity. 


The patient is requested to inhale deeply and as he does so, the 
gall-bladder will be forced out through the incision where its position 
may be maintained during exploration (Figs. 191 and 192). While 
the liver advances during deep inspiration its edge may be retained 
by means of gentle pressure with a retractor and, as the process 
is repeated, it will effect a slight rotation of the liver within the 



one’s view of the gall-bladder and in certain individuals it may 
be possible, by continuing this process, to deliver the gall-bladder 




GALL-BLADDER AND DUCTS 


443 


well out of the abdominal cavity. One should be careful to avoid 
traction upon the gall-bladder and should be satisfied with simple 
retention of the organ in the position to which it is brought by the 
patient’s respiratory efforts. (Figs. 195, 196 and 197.) 



Anterior Splanchnic Anesthesia.—As soon as this process has been 
carried out to the extent which allows one to visualize the region 
of the origin of the cystic duct, anterior splanchnic anesthesia may 















444 


SURGERY OF THE UPPER ABDOMEN 


be established. This is accomplished by the introduction of a 
few cubic centimeters of novocain-adrenalin solution just beneath 



Fig. 193.—Gall-bladder. Saggital view. Showing rotation of liver and exposure 
of gall-bladder. (Anterior splanchnic anesthesia, shown in Fig. 29. From Ani¬ 
mated Motion Pictures.) 

the peritoneum on either side of the line of the common duct and 
as high up as possible (Fig. 193, and Fig. 29, page 128). In certain 
cases one may now remove the gall-bladder by first dividing the 














GALL-BLADDER AND DUCTS * 445 

cystic duct (tig. 194). However, it has been found much more 
simple to remove the gall-bladder fundus first, simply because 


Fig. 194. —Gall-bladder (cholecystectomy). Clamping of cystic duct. 




Fig. 195 —Gall-bladder, gauze tractor. Photograph of Case No. 1.3722 undergoing 

cholecystectomy. 








SURGERY OF THE UPPER ABDOMEN 


446 


the fundus is the first portion met and may be attacked without 
as much manipulation as is found necessary if the attack is to 
be begun at the cystic duct. 

Large, thickened gall-bladders, or those acutely distended and 
upon which forceps cannot be applied, may often be controlled by 
the gauze retractor (see Fig. 35, page 159). 

Fig. 195 shows a patient undergoing an operation. The gall¬ 
bladder is being controlled by the use of the gauze tractor. It 
may be noted that this organ is enlarged, its walls thickened and 
that the use of the gauze tractor greatly facilitates its manipulation. 

Technic of Exposing the Ga,ll-bladder.—The patient may at will, by 
making a deep inspiration, show the gall-bladder or a large portion 
of the stomach to the surgeon, or even to the spectators. The 
pathological conditions may be noted and digital examination, 
if carefully made, may be carried out almost to any extent, pro¬ 
vided traction is avoided. By retracting the abdominal wall 
upward adhesions may be visualized (Fig. 170, page 396) and 
treated by cutting along the white line without the least difficulty. 
The greatest difficulty is encountered in heavy, obese individuals, 
whose livers lie well above the costal border. In these patients 
it may be best to establish a posterior splanchnic anesthesia by 
the method of Kappis (page 124) before entering the abdomen. 
However, the use of the reversed Trendelenburg position and forced 
inspiration has made it possible to visualize the gall-bladder and 
to establish splanchnic anesthesia by the anterior method in nearly 
all cases. 

The Method of Removing the Gall-bladder.—Before excision of the 
gall-bladder is begun the needle is inserted beneath the peritoneal 
coat of the gall-bladder, close to the liver edge (Fig. 191, page 442), 
and the organ is “blown off,” or, in other words, separated 
from the liver surface by forcefully injecting novocain-adrenalin 
solution. The peritoneal coat may then be divided and the dis¬ 
section completed. The time required for freeing the gall-bladder 
allows the anterior splanchnic anesthesia to take effect. Not 
infrequently the anesthesia is so profound that sufficient traction 
may be made upon the gall-bladder to tear the cystic duct directly 


in two without affording the patient pain. After the removal of 
the gall-bladder the common and hepatic ducts may be explored 
without embarrassment, provided the lower edge of the liver is 
well inverted beneath the costal margin (Fig. 193, page 444). In 
the author’s experience the delivery of a considerable portion of 
the liver upon the chest wall is not tolerated by the conscious 
patient without complaint of pain and, indeed, the patient under 
general anesthesia will in every instance resent profoundly this 
insult, as is evidenced by the increase in pulse rate, the change 
in the frequency and depth of respiration, signs which call for 


GALL-BLADDER AND DUCTS 


447 


deep anesthesia. Splanchnic anesthesia should be established before 
the operative procedure on the gall-bladder is begun providing 
exposure can be obtained. 

The following case involved the gall-bladder, stomach and 
appendix. 

Report of Case No. 11521. 

J. H. C., aged forty-five years, entered the hospital May 9, 1918. 

Diagnosis: Cholecystitis; cholelithiasis; pyloric stenosis; recur¬ 
rent appendicitis. 

Operation: (’holecystectomv; pvloroplastv; appendicectoniv, Mav 
11, 1918. 

Technic of Anesthesia: 150 cc of a 0.6 of 1 per cent novocain- 
adrenalin solution were used in making an “L” infiltration of the 
abdominal wall. (Fig. 163, page 390 and Fig. 190, page 440.) The 
abdomen was opened with a negative pressure and the liver was 
extremely high. The gall-bladder was white, thickened and 
contained stones. The pylorus was rigid and contracted from 
the scar of an ulcer. With the patient in reversed Trendelenburg 
position the liver edge was turned upward by means of a smooth 
retractor, the gall-bladder was grasped and the patient requested 
to take a number of deep inspirations. By this method the region 
of the cystic and common ducts was visualized and anterior splanch¬ 
nic anesthesia was established. The gall-bladder was removed, 
fundus first, and pyloroplasty was then performed. The patient 
was then tilted to the left and the Trendelenburg position taken. 
Vertical retraction showed the appendix and it was grasped and 
removed in the usual manner. x4 cigarette drain was placed through 
the upper flap of the incision. 

Note .—This patient did not vomit following her operation. She 
returned to bed with a pulse of 80 and made an uneventful recovery. 

The following case is cited to illustrate the use of local anesthesia 
in acute septic conditions associated with the gall-bladder: 


Report of Case No. 14207. 

1). R. S., physician, aged forty-eight years, entered the hospital 
March 30, 1921. 

Diagnosis: Suppurative cholecystitis; cholelithiasis; perforation 
of gall-bladder; localized peritonitis. 

Anesthesia: Local infiltration. 

Operation: Incision and drainage. 

History: Patient has had frequent attacks of upper abdominal 
cramps which are evidently associated with the gall-bladder. Two 
weeks prior to his entry into the hospital he had suffered a severe 
attack of pain similar to his former attacks, followed by a rise of 


448 


SURGERY OF THE UPPER ABDOMEN 


temperature and extreme illness. His temperature averaged 102° 
since the beginning of this attack. Examination showed a distinct 
tumor in the upper abdomen in the region of the gall-bladder. 
The mass was extremely tender. A diagnosis of localized abscess, 
with probable gall-bladder perforation, was made. 

Technic of Anesthesia: Infiltration, using 120 cc of a 0.7 of 1 
per cent novocain-adrenalin solution in the abdominal wall. 

The right rectus muscle was divided and the general peritoneal 
cavity opened without the extrusion of the viscera. All tissue 
was divided between forceps which elevated the abdominal wall, 
thus avoiding pressure upon the tumor which was extremely tender. 
Above the incision the tumor mass was seen to be adherent to the 
parietal peritoneum. The general peritoneal cavity was packed 
and a blunt-pointed forceps used to separate the line of adhesions. 
From 200 to 300 cc of thick, creamy, bile-stained pus was evacuated 
by suction and a number of gall-stones were found lying free in 
the cavity of the abscess. 

This patient was in a critical condition, with marked myocardial 
degeneration and albumin and casts in the urine. He had been 
taking huge doses of morphine for two weeks and although extremely 
septic and nervous, he went through the operation without any 
material change in his condition and he stated that he enjoyed it. 

This case furthermore illustrates the use of local anesthesia in 
acute septic conditions in the upper abdomen as well as the facility 
with which extensive operative procedures may be carried out if 
surgical interference becomes necessary and the hazard connected 
with the use of inhalation anesthesia is considered to be too great. 

Two weeks following the operation he was up in a chair and he 
made an uneventful recoverv. 


Report of Case No. 13722. 

Mrs. A. C. E., aged thirty years, entered hospital March 15, 1920. 

Diagnosis: Hydrops of the gall-bladder. 

Operation: Cholecystectomy. 

Technic of Anesthesia: 120 cc of a 0.5 of 1 per cent novocain- 
adrenalin solution. No preliminary hypodermic medication. 

An “L” infiltration of the abdominal wall and an “L” incision 
dividing the right rectus muscle between clamps were made. 
The gall-bladder was large, firm and distended. The pancreas, 
duodenum and stomach were examined, but the colon and small 
intestine were not se<?n. The pylorus, duodenum and Morris’s 
pouch were gently excluded by gauze packs and the use of wire¬ 
spring retractors. Voluntary, forced inspiration caused the gall¬ 
bladder to protrude well outside the abdominal cavity, after which 


GALL-BLADDER AND DUCTS 


449 


gentle traction upward brought the region of the cystic duct into 
view. (Figs. 191, page 442, and 194, page 445, and 29, page 128.) 
A long fine needle was inserted first to the right and then to the 
left of the common duct through the posterior parietal peritoneum, 
and 10 cc of the solution introduced upon each side of the common 
duct. 1 he needle was then inserted between the gall-bladder 
and the liver at the point of their distal attachment, and a liberal 
supply of solution injected between the two organs. The photo¬ 
graph shows the ease with which the gall-bladder was visualized 
under this technic. (Fig. 196.) 



Fig. 196. —Gall-bladder (cholecystectomy). Photograph of Case No. 13722 during 
operation. Note exposure obtained without dislocating the liver. 


Report of Case No. 14398. 

Mrs. G. H., aged thirty-five years, entered hospital September 
26, 1921. 

Diagnosis: Pulmonary tuberculosis (active); cholecystitis.; chole¬ 
lithiasis; recurrent appendicitis. 

Operation: Cholecystectomy; appendicectomy. 

History: The patient has had tuberculosis of the lungs with 
sanatorium treatment for eight years and her condition improved. 
The abdominal condition dates back four months. Gastric symp¬ 
toms were so severe that they interfered with the patient’s nourish¬ 
ment and she was referred by Dr. J. W. Marcley, who felt that 
unless her nourishment could be improved she would rapidly 
succumb on account of her pulmonary condition. The patient 
had also had several attacks of acute appendicitis. Accordingly 
cholecystectomy and appendicectomy were performed at one sitting 
under local anesthesia. I >r. Marcley thought it would be extremely 
dangerous to establish general anesthesia in such a case. In fact, 
29 





450 


SURGERY OF THE OFFER ABDOMEN 


her attacks of acute appendicitis had been treated expectantly on 
this account. 

Fig. 197 shows a picture of the patient while undergoing operation, 
the cystic duct being plainly visible in the field. The patient 
withstood the operation without any signs of trouble and without 
appreciable effect on the lung condition. The gastric symptoms 
have entirely disappeared. 



Fig. 197.—Gall-bladder. Photograph of Case No. 14398, showing voluntary 
exposure of gall-bladder and cystic duct. 


The possibility of making multiple incisions and doing multiple 
operations under local anesthesia is illustrated by the following 
case: 

Report of Case No. 10073. 

J. M. I)., aged thirty years, entered hospital September 12, 1917. 

Diagnosis: Appendicitis; cholecystitis; uterine retroversion. 

Operation: Appendicectomy; cholecystectomy; hysteropexy. 

Anesthesia: Local infiltration (multiple incisions) anterior 
splanchnic. 

History: The patient was a deaf mute and it was therefore 
difficult to obtain a history of her symptoms, which were more 
or less obscure. She was just over a well-established attack of 
acute appendicitis which had begun several days previously. She 
was placed on management for a few days until she had entirely 
recovered. Iler history showed that she had had undoubted 
attacks of cholecystitis and on bimanual examination the uterus 
was found to be retroverted, which fitted her symptoms of back¬ 
ache. 




GALL-BLADDER AND DUCTS 


451 


Technic oj Anesthesia: Twelve days after entrance to hospital, 
classical infiltration block was made using 60 cc novocain-adrenalin 
solution of 0.5 of 1 per cent. The gridiron incision showed the 
appendix in the pelvis and practically normal. It was removed 
through the incision, which was small. The right rectus was 
then divided after an infiltration block across it and the gall-bladder, 
which was white and thickened, and to which the omentum was 
adherent, was removed after making an anterior splanchnic infil¬ 
tration. These two operations having consumed but forty minutes 
and the diagnosis having been changed after exploration had been 
made to subacute cholecystitis rather than appendicitis and the 
patient being in excellent condition, it was deemed advisable to 
replace the uterus in its normal position. Accordingly a midline 
infiltration and incision was made below the navel, the round 
ligaments shortened and the abdomen closed. This patient made 
an uneventful recovery. 

Note .—But 210 cc of novocain-adrenalin solution were used 
in order to carry out the three operations. The time required for 
making the three operations was one and a half hours, including 
the making of the infiltration and the closure of the three incisions. 
From the standpoint of diagnosis this case is not especially gratify¬ 
ing; however, it illustrates the comparative ease with which one 
may carry out multiple procedures under the use of local anesthesia. 
The error in diagnosis in this case must be given as the reason for 
making three incisions instead of two. However, we have in a 
number of instances operated for conditions in the upper abdomen 
and the lower abdomen, besides doing vaginal work, all at one 
sitting and with no more embarrassment than when general anes¬ 
thesia is employed. 

As examples of the extensive operative manipulation in the 
abdomen under local anesthesia the following cases may be cited: 


Report of Case No. 15427. 


Mrs. 


G. M., aged thirty-four years, 


entered the hospital January 


26, 1922. 

Diagnosis: Subacute cholecystitis; viscero-parietal adhesions; 
retroversion of the uterus and right ovarian cyst. 

Operation: Cholecystectomy; division of adhesions; excision of 


ovarian cyst; and hysteropexy. 

Anesthesia: Local infiltration block. 

History: Patient had been operated upon five years before by 
the author for exophthalmic goiter, local anesthesia being used. 
She made a perfect recovery from this operation, and has remained 


452 


SURGERY OF THE UPPER ABDOMEN 


well as far as her thyroid is concerned, but the patient now comes 
to hospital for treatment of abdominal condition. 

Technic of Anesthesia: The abdomen presented four vertical 
scars, the result of former operations, and an infiltration block was 
made at the edge of the right rectus muscle on one side of the 
scars and along the midline on the other side extending from the 
costal border to a point 8 cm. below the umbilicus, 250 cc of a 1 
per cent solution of novocain-adrenalin being used. 

The old scars in the skin were excised and a right midline incision 
25 cm. long was made, with the patient in the Trendelenburg 
position, a perfect negative pressure, and a pelvis free of intestines 
was obtained. Several loops of small bowel and a large amount 
of the greater omentum were found adherent to the parietal peri¬ 
toneum. The adhesions were all divided without reinforcing the 
anesthesia. The round ligaments were plicated. A right ovarian 
cyst the size of an orange was removed after blocking the ovarian 
pedicle. The lower 8 cm. of the incision were sutured and a reverse 
Trendelenburg position was substituted for the Trendelenburg 
and the upper abdominal viscera examined. The diagnosis of 
cholecystitis was confirmed. The stomach, colon and duodenum 
were carefully excluded from the field by means of pads and the 
wire spring retractors, and the gall-bladder was removed by the 
technic described on page 440. The time required for the completion 
of the operation including the introduction of the anesthetic was 
one hour. The patient’s pulse was 80 at the completion of the 
operation. She did not vomit following the operation but developed 
a slight bronchitis the following day. Her temperature rose to 
100.4° and her pulse to 100 on the second day, but on the sixth 
day both were normal. 

Note .—This case illustrates a considerable series of this type in 
which multiple operations have been done under direct infiltration 
of the abdominal wall with practically the same facility one would 
meet in carrying out the same procedure on the cadaver. 

As an example of the removal of both the gall-bladder and 
appendix, through a trans-rectus incision, the following case may 
be cited: 

Report of Case No. 10008. 


Diagnosis: Chronic cholecystitis; recurrent appendicitis. 

A. M., entered hospital August 22, 1917. 

Operation: August 23, 1917: Cholecystectomy; appendicectomy. 
Technic of Anesthesia: Local infiltration; anterior splanchnic; 
novocain-adrenalin solution, 120 cc of a 0.5 of 1 per cent being used. 

A transverse infiltration was made across the right rectus, 3 cm. 
above the umbilicus. The anesthesia was continued from the 


BILE DUCTS 


453 


outer end of this line diagonally along the costal margin. The 
right rectus was divided between muscle clamps and the abdomen 
presented perfect negative pressure. The stomach, pylorus and 
duodenum were palpated and examined visually and were found 
to be normal. The gall-bladder was large and white and pressure 
upon this viscus reproduced some of the patient’s former symp¬ 
toms. A clamp was placed upon the fundus and the patient 
instructed to take repeated deep inspirations. An anterior splanch¬ 
nic anesthesia was produced by the injection of novocain-adrenalin 
solution in the region of common and cystic ducts which came 
plainly into view even without the use of abdominal packs. The 
gall-bladder was removed fundus first, the cystic duct divided 
between clamps and ligated with catgut. A cigarette drain was 
brought out through a stab wound 2 cm. above the incision. 

The patient was placed in the Trendelenburg position and 
rotated to the left. Vertical retraction of the outer angle of the 
incision showed the appendix adherent at the pelvic brim, also the 
presence of an extensive pericolic membrane. By the use of long 
instruments and good light the peritoneal attachments were 
separated, when the appendix and cecum were brought into the 
wound and removed in the usual manner. Our records show that 
the appendix and gall-bladder were removed in this case through 
a right trans-rectus “compromise” incision with little difficulty. 
The use of strategy, the tilting of the table and the presence of a 
negative intra-abdominal pressure and the use of anterior splanch¬ 
nic anesthesia were important sheet anchors in the successful 
accomplishment of this result. 

BILE DUCTS. 

Choledochotomy.— An exploration of the ducts may be carried 
out in most cases. In all cases where the stomach, duodenum, 
colon and liver are properly retracted and splanchnic anesthesia 
established the ducts can be gone over methodically and completely 
under this form of anesthesia. Exposure is the main strategic 
aim and may generally be achieved by the means described above. 

When there is difficulty in delivering the gall-bladder on account 
of a high-lying liver, extensive adhesions, or from any other cause, 
the procedure may be carried out, although with more difficulty, 
by following approximately the same methods as those described 
above, and working within the abdomen rather than outside. 
This kind of work requires a perfect light, the use of long, delicate 
instruments and small fine needles, and is facilitated by making 
use of the forceps tie. The hands should remain outside. 

To summarize therefore, a perfect anesthesia of the abdominal 


454 


SURGERY OF THE UPPER ABDOMEN 


wall, which abolishes the reflexes and allows one to obtain a 
negative pressure when opening the peritoneal cavity and strategic 
measures while operating, aided by splanchnic anesthesia, allows 
one to deal effectively with the surgical diseases of the gall-bladder 
and ducts in the vast majority of cases without resorting to general 
anesthesia. 

The following case is one of common bile duct obstruction treated 
surgically after the above method. 

Report of Case No. 10174. 

J. R. A., aged fifty-eight years, entered the hospital October 28, 
1917. 

Diagnosis: Cholelithiasis; common duct obstruction. 

Operation: Cholecystectomy; choledochotomy. 

Anesthesia: Local infiltration; anterior splanchnic. 

History: Patient had had frequent attacks of gall-bladder colic. 
One month ago, severe attack of colic followed by relief with jaundice 
and clay stools. Jaundice is now nearly cleared up. The patient 
is still pale. The stools show presence of bile and the clotting- 
time of blood is normal. 

Technic of Anesthesia: The local infiltration required 120 cc 
novocain-adrenalin solution. An “L” incision was made and 
the right rectus was divided between clamps. A small white 
gall-bladder was found adherent to the duodenum. Adhesions 
were divided with scissors and anterior splanchnic anesthesia 
was established. After a number of deep inspirations had been 
taken by the patient and the gall-bladder, which had been grasped 
by forceps, had been turned upward, cholecystectomy was per¬ 
formed. The common duct was opened and a number of stones 
removed. A Kehr tube was sutured into the common duct and 
the abdomen was closed with drainage. The patient’s pulse at 
end of the operation was 80. Recovery was uneventful. 

The next case will illustrate the facility with which desperate 
surgical risks may be operated upon under local anesthesia pro¬ 
vided certain principles be observed in carrying out the operation: 

Report of Case No. 13787. 

A. 0., aged seventy-three years, entered hospital September 
15, 1920. His maximal weight was 80 kilos, and his weight at the 
time of entering the hospital was 66 kilos. 

Diagnosis: Cholecystitis; cholelithiasis; common duct stone. 

Operation: Cholecystotomy and choledochotomy. 

Anesthesia: Local infiltration; anterior splanchnic. 


BILE DUCTS 


455 


History: For thirty years the patient had had frequent attacks 
of pain in the upper abdomen, with vomiting and jaundice. Five 
years prior to his entry into the hospital he had been jaundiced 
for a short time, and two weeks before entering lie had had several 
attacks of severe pain, accompanied by jaundice. The jaundice 
increased, and his temperature ranged from 98° to 105°, being of 
the “steeple” variety. When he entered the hospital the clotting 
time of his blood was six minutes, and he was having frequent 
rigors. A diagnosis of cholecystitis, cholelithiasis, and a common 
duct stone was made, and it was thought best to operate 
immediately. 

Technic of Anesthesia: Classical infiltration block (see Fig. 190, 
page 440). 

The abdomen was opened with extreme care, using an “L” 
incision. The right rectus was divided and a vertical limb of the 
incision was carried up to the ensiform. A marked localized peri¬ 
tonitis presented in the region of the gall-bladder. The field was 
carefully packed off with gauze pads, and wire-spring retractors 
were inserted. A perfect exposure was obtained. An attempt 
was made to grasp the thickened and distended gall-bladder, but 
this was impossible both on account of the pain produced and 
because of our inability to find sufficient slack in the gall-bladder 
wall to grasp it. The liver was therefore gently retracted upward 
and an anterior splanchnic anesthesia established by injecting on 
either side of the common duct which came plainly into view. 
The gall-bladder could then be manipulated without distress 
to the patient. It was aspirated and found to contain creamy 
pus. The common duct which was greatly distended was opened 
and the overflow of bile removed by suction, after which an impacted 
stone was removed. A Kehr tube was introduced and the common 
duct sutured over this with chromic gut. The gall-bladder was 
then opened and several stones were removed. A cholecystostomy 
was performed and the tubes brought out through a stab wound 
in the upper flap. The patient’s pulse rate remained 75 throughout 
the operation. 

The time required for the administration of anesthesia and the 
completion of the operation was forty minutes. The patient made 
an uneventful recovery with the exception of the development 
of a parotitis on the right side. 

Note .—This case serves to illustrate the use of local anesthesia 
in acute septic conditions in the upper abdomen, and also shows 
the facility with which extensive operative procedures may be 
carried out under local anesthesia if it becomes necessary to inter¬ 
fere surgically and the hazard accompanying inhalation anesthe¬ 
sia is considered excessive. This operation was entirely without 


456 


SURGERY OF THE UPPER ABDOMEN 


shock to the patient and at the end of the operation he was in every 
way in as good condition as he was at the beginning. 

The following case illustrates the use of local anesthesia in the 
presence of complications: 


Report of Case No. 14301. 

W. M., aged fifty-eight years, entered the hospital June 13, 1921. 

Diagnosis: Cholecystitis, with a common duct stone; viscero- 
parietal adhesions. 

Operation: Cholecystectomy; choledochotomv; freeing of viscero- 
parietal adhesions. 

Anesthesia: Local infiltration; anterior splanchnic. 

Pneumoperitoneum was performed, using oxygen. Cholelithiasis 
was demonstrated by means of radiograms after inflation. 

Technic of Anesthesia: Infiltration, novocain-adrenalin 200 cc 
of a 0.7 of 1 per cent solution being used. A 15 c*m. right rectus 
incision was made with the patient in reversed Trendelenburg 
position. The abdomen was opened with a perfect negative pres¬ 
sure which seemed to be facilitated by the presence of a portion 
of the oxygen which had been injected the previous day (see page 
95). Viscero-parietal adhesions at the lower end of the incision 
at the site of the scar of a former operation were divided. The 
gall-bladder, which was white and thickened and contained many 
stones, was grasped with a hemostat and the patient instructed 
to breathe deeply. In this manner the posterior parietal peri¬ 
toneum was visualized and infiltrated with the anesthetic solution. 
Packs were then introduced one to the right in Morris’s pouch, 
one to the left against the pyloric end of the stomach and one 
below, between the gall-bladder and duodenum. Three No. 6 wire¬ 
spring retractors were introduced, thus carrying the stomach and 
colon out of the field. At this juncture a stone could be seen and 
felt in the common duct. A needle was inserted between the 
gall-bladder and the liver beneath the peritoneum. 15 cc of the 
solution were introduced and the gall-bladder removed, fundus 
first, leaving 2 to 3 cm. of the cystic duct as a handle for the identi¬ 
fication of the common duct. The common duct was opened and 
the stone removed. (The common and hepatic ducts were opened 
directly under the vision.) The common duct was then sutured 
with fine chromic gut, a cigarette drain carried through the 
abdominal wall and the wound closed. 

In this patient, who was fairly heavy, the common duct was 
brought to the level of the rectus muscle during the exploration. 
The operation was painless, and at the close of the operation the 
patient’s pulse was 70. 


THE PANCREAS 


457 


THE PANCREAS. 

The pancreas may be examined and even manipulated to some 
extent without any special distress to the patient. An anterior 
splanchnic anesthesia gives one a sufficient opportunity for the 
removal of concretions from the pancreatic ducts. 

Pancreatic cysts may be opened and drained without the use of 
intraperitoneal anesthesia, although the cyst wall may be infil¬ 
trated as it comes into view. Under local anesthesia this is a 
comparatively simple procedure. The following case report will 
serve to illustrate the technic: 

Report of Case No. 13824. 

J. W., aged fifty-one years, entered the hospital June 3, 1920. 

Diagnosis: Pancreatic cyst. 

Operation: Abdominal exploration; excision and drainage of 
cyst. 

Anesthesia: Local infiltration. 



Fig. 198.—Pancreatic cyst. Photograph of Case No. 13824 during operation. 

History: Patient presented a large tumor in upper abdomen. 
June 4, a pneumoperitoneum was done and roentgenograms taken. 

Technic of Anesthesia: The infiltration of skin and rectus muscle 
required 150 cc. A vertical incision was made. A cyst the size 
of the patient’s head presented, with the stomach just below it. 
The gall-bladder was large and white. The cyst was opened and 
evacuated by suction. The wall was 0.5 cm. thick filled with dark 
thin fluid. The posterior wall presented many dark blue hard 
nodules. Frozen sections showed carcinoma. Cyst packed with 
iodoform gauze and wound partially closed. Anesthesia was ideal. 
The patient’s pulse, at end of operation, was 70. 

I 7 ig. 198 shows the patient during the operation while the cyst 
was being aspirated. 





458 


SURGERY OF THE UPPER ABDOMEN 


THE SPLEEN. 

The spleen may be removed after simple infiltration of the 
abdominal wall, combined with a liberal infiltration of the splenic 
pedicle beneath the peritoneum or after the use of a posterior 
splanchnic anesthesia of the left side. 

The incision should be liberal, the patient should be in the reverse 
Trendelenburg position and tilted to the right. When anterior 
splanchnic anesthesia is to be used, a good exposure of the pedicle 
should be obtained by means of vertical retraction. 

The size and mobility of the organ will serve as a guide. Large 
or immobile spleens demand the preliminary establishment of the 
anesthesia of Kappis. 

Posterior splanchnic anesthesia as a preliminary is satisfactory 
for this operation. 


CHAPTER XVI. 


LOCAL ANESTHESIA IN SURGERY OF THE 

INTESTINES, 

Special Considerations.—In a consideration of the use of local 
anesthesia in the treatment of surgical conditions of the intestines, 
the subject naturally divides itself into two phases: 

0) Treatment of Simple Conditions .—Under this are included 
operations of every nature upon the free and easily movable bowel, 
namely, resection, enteroanastomosis, colostomy, enterostomy, and 
other operations in which the indications are met with compara¬ 
tive ease after the establishment of anesthesia of the abdominal 
wall. 

(6) Treatment of Complicated Conditions. — The treatment of 
complicated conditions involves excision for malignant disease and 
complicated intestinal obstructions, especially those of obscure 
origin. 

Diagnosis.—The carrying out of procedures within the abdomen 
is greatly simplified by the preliminary establishment of an accurate 
diagnosis, which permits proper planning of the abdominal incision 
both as regards length and location. 

Treatment of Simple Conditions.—The surgical treatment of the 
more simple intestinal conditions under local anesthesia may be 
carried out with facility and dispatch, provided perfect anesthesia 
of the abdominal wall is established and the proper strategy 
employed. 

The obtaining of a perfect negative intra-abdominal pressure, 
the use of the force of gravity to carry the viscera away from the 
field of operation by the tilting of the table, combined with the 
absence of expulsive effort, go far toward bringing this type of 
surgery close to ideal. Intestinal resection, enterostomy, colos¬ 
tomy, enteroanastomosis and, in fact, all operative procedures 
upon the free intestine may be carried out without great embarrass¬ 
ment provided traction can be avoided, and, fortunately, one may 
by the use of splanchnic anesthesia even find it possible to exert 
considerable traction if this should become necessary. The silent 
field, the absence of expulsive effort, the opportunity offered for 
deliberation and the possibility of avoiding trauma are of decided 
technical advantage in carrying out the above-mentioned operations 
under local anesthesia. 


460 


SURGERY OF THE INTESTINES 


Treatment of Complicated Conditions.—In this group may be placed 
all of the other surgical conditions of the intestines which occur, 
excepting those mentioned above, such as malignant disease of 
the intestine—conditions produced by the various forms of perito¬ 
nitis, tuberculous conditions, and acute and chronic intestinal 
obstruction from any cause, including intussusception. In con¬ 
sidering the surgery of such diseases it may be well to go into 
detail regarding the management of a number of conditions in 
order to illustrate the manner of meeting and overcoming some 
of the difficulties which present themselves. 

The following article by the author is an example of a simple 
means of caring for the septic end of the bowel or other viscera 
when doing abdominal surgery. 

A Simple Method of Excluding the Septic End of the 
Bowel during Intestinal Resection. 1 

“In doing an intestinal resection, numerous methods have 
been devised for protecting the peritoneal cavity from contami¬ 
nation. The remaining ends of the bowel may be sterilized by 
cauterization or inverted, and the same treatment may be accorded 
the portion of the bowel which is to be excised, but this takes time. 
For the method recommended the materials and the septic bowel 
may be excluded in an instant after its division without the slightest 
possibility of contamination. 

“At the first point of division of the bowel a heavy clamp is 
placed upon the portion which is to remain, while the portion to 
be excised is grasped by a long-handled forceps, the blades of which 
have been inserted into two fingers of a sterilized glove (Fig. 199) 
After the division of the bowel by knife, scissors or cautery the 
end that is to remain may be treated in the usual manner. The 
end which is to be removed is held in the forceps, as illustrated 
(Fig. 200); the operator then grasps the glove at point C with his 
left hand, and his assistant grasps the glove at points A and B. 
By making traction, the sleeve of the glove assumes a triangular 
form, the septic end is then made to disappear by making traction 
upon the forceps, the glove being turned inside out over the bowel 
and there securely clamped by means of a forceps. 

“ Th is principle may be applied in many other operations where 
a septic mass with a pedicle is to be isolated.” 

Resection for Cancer.—The possibility of establishing a suffi¬ 
ciently profound local anesthesia to permit the excision of malig¬ 
nant growths in the colon will depend in some measure upon the 

1 Farr, R. E.: Surg., Gynec. and Obst., March, 1919. 


RESECTION FOR CANCER 


461 

location and extent of the growth, and the mobility of the involved 
gut. As a ride the greatest difficulty encountered will be met in 



Fig. 199.—Grasping end of septic bowel before reversing glove. 


dealing with growths involving the colonic flexures. However, 
we have been able, by making use of the lateral tilt and paraverte¬ 
bral and splanchnic anesthesia, combined with adequate incisions, 



Fig. 200.—Reversing glove over septic end of bowel. 


to resect growths in each of the colonic flexures without pain to 
the patient. The greatest aid in carrying out this work is the 





SURGERY OF THE INTESTINES 


402 


attainment of a negative intra-abdominal pressure upon entering 
the peritoneal cavity. Under these conditions the colonic mesentery 
may be exposed and blocked before any further manipulation is 
carried out. It is well to introduce a liberal amount of the solution 
in the region of the large vessels, and to follow this by a direct 
infiltration of the external peritoneal leaf, after which the colon 
may be mobilized without embarrassment. A great barrier to 
the carrying out of this technic is the presence of distention, but 
this may usually be anticipated and prevented by proper pre¬ 
paratory treatment. In the presence of obstruction, and in fact 
in other cases as well, we have made it a rule to precede the radical 
operation by the performance of a colostomy, thereby reducing 
to a minimum the number of cases in which distention is found 
(see page 463). 

The benign influence of local anesthesia and operations per¬ 
formed under its use is especially desirable in this class of cases, 
which should be operated upon whenever possible by the fractional 
method. 

The operation for the excision of the sigmoid or rectosigmoid 
may be done painlessly after an infiltration block of the mesentery, 
and an anterior splanchnic anesthesia, combined with infiltration 
block of the external peritoneal leaf of the sigmoid colon. The 
solution may be used liberally in these regions if precautions are 
taken against its introduction into the circulatory system, and a 
perfect anesthesia will almost immediately ensue. The Kraske 
operation may be carried out under trans-sacral anesthesia (see 
page 117). 

The treatment of malignant disease of the rectosigmoid is best 
carried out by the multiple operation method. The author pre¬ 
fers to divide the surgical treatment into three operations as illus¬ 
trated in the following case. 


Report of Case No. 14312. 

Miss F. 1)., aged forty-two years, entered the hospital June 20, 
1921. 

Diagnosis: Carcinoma of rectosigmoid. 

Operations: First, preliminary cecostomy, June 21, 1921. 

Second, resection of the rectosigmoid, July 16, 1921. 
Third, closure of the colostomv wound, October 4, 
1921. 

First Operation: Cecostomy. 

Technic of Anesthesia: Local infiltration 60 cc of a 1 per cent 
novocain-adrenalin solution. Gridiron incision. The cecum was 
grasped by rubber-tipped thumb forceps and its mesentery infil- 


I NT USS USCEPT1 ON 


463 

trated. lhe cecum was then delivered, its mesentery perforated 
and a sealed glass catgut tube introduced transversely beneath 
the cecum through a perforation and anchored to the skin with 
catgut sutures. 

Second Operation: Resection of rectosigmoid. 

Technic of Anesthesia: Preliminary sacral, 90 cc of a 1 per cent 
novocain-adrenalin injection; direct infiltration of abdominal wall, 
120 cc of a 1 per cent novocain-adrenalin solution and anterior 
splanchnic. 

The patient was placed in the Trendelenburg position, and a 
perfect negative pressure was obtained. Enlarged glands were 
exposed at the pelvic brim. Anterior splanchnic anesthesia was 
then established, the solution being introduced beneath the parietal 
peritoneum above the glands. The colonic mesentery was also 
infiltrated. The procedure of Balfour was carried out under 
ideal anesthesia, and the segment of bowel removed was approxi¬ 
mately 45 cm. long. Pelvic drainage was introduced, the drains 
being brought out between the anus and coccyx. The patient 
became rather pale at the completion of the operation and com¬ 
plained of being tired. 

Third Operation: closure of the cecum. 

Technic of Anesthesia: Circumferential infiltration block using 
120 cc of a 1 per cent novocain-adrenalin solution. 

Note .—This patient went through the three steps of this pro¬ 
cedure without nausea, vomiting, gas pains, thirst or shock, and 
her operations were painless. 

Colostomy.—Preliminary anesthetization of the abdominal wall 
is carried out along the lines laid down for incision of the abdominal 
wall (pages 149—153). A midline or other incision may be made 
for the purpose of examining the growth, presence of metastasis, 
etc. 

Technic of Operation.—The portion of the bowel which is to be 
delivered is located by means of direct vision and picked up in 
long rubber-tipped intestinal forceps. The mesentery is blocked by 
the introduction of 10 to 30 cc of a 0.1 per cent novocain-adrenalin 
solution. The mesentery is then perforated by means of a sharp- 
pointed artery forceps which is spread sufficiently to allow the 
introduction of a glass catgut tube which has not been previously 
opened. Silkworm stitches through the skin retain each end of 
the tube in position. When the method of Mikulicz is to be 
employed the technic differs only in the making of a slightly larger 
incision. 

Intussusception.—This disease, which appears most commonly 
in children, may be treated under local anesthesia, and the critical 
condition in which the patient frequently conies for operation 


464 


SURGERY OF THE INTESTINES 


makes the use of local anesthesia especially desirable. The author 
has treated but one case in the adult under local anesthesia and 
in this case the operation was performed successfully under local 
infiltration. 


Report of Case No. 13965. 

B. M., aged twenty-six years, entered hospital January 20, 1920. 

Diagnosis: I n tu ssu seeption. 

Operation: Reduction of intussusception. 

History: Patient had a partial intestinal obstruction for six 
days. Pneumoperitoneum—radiographs showed a mass extend¬ 
ing transversely across the upper abdomen. 

Preoperative Diagnosis: Volvulus or intussusception. 

Technic of Anesthesia: Saligenin, 2 per cent. Transverse infil¬ 
tration 2 cm. above umbilicus, 180 cc of solution used. 



Fig. 201.—Intussusception. Photograph (retouched) of Case No. 13965 during 

operation. 


The incision was made immediately and a perfect negative 
pressure was obtained. Examination showed an intussusception 
at the ileocecal valve. No intraperitoneal anesthesia was used. 
The proximal attachment of the mass extended toward the pelvis. 
Accordingly, the incision was enlarged downward in the sheath 
of the rectus a distance of 8 cm. after infiltrating this area. The 
intussusception was “milked” out of the intussuscipiens without 
difficulty and without distress to the patient, as shown in Fig. 
201. The ileum was then sutured to the ascending colon and the 
incision closed. Uneventful recovery. 

Note.— Reduction in this case was made without difficulty and 
without pain, although the use of some force was necessary. The 
technic would undoubtedly have been improved had the colonic 
mesentery been blocked. 

In this connection I desire to refer to a personal communication 
received from Dr. P. B. McLaughlin of Sioux City, Iowa, in which 








INTUSSUSCEPTION IN CHILDREN 


lie states that during an operation for intussusception in an adult, 
performed under local anesthesia in February, 1922, he found it 
impossible manually to reduce the bowel which was invaginated 
for a distance of 40 cm. As the patient complained of pain, he 
injected the intestinal mesentery with novocain-adrenalin solution, 
and had the satisfaction of observing a complete relaxation of 
the intestinal musculature, releasing the invaginated bowel. lie 
states that the intussusception released itself almost spontaneously. 
This communication is so recent that the author has had no oppor¬ 
tunity to verify it in his own work. However, it would seem reason¬ 
able to suppose that the abolishment of the muscular spasm would 
bring about the result described. 

Intussusception in Children.—For a number of years, all cases 
of intussusception in children have been operated upon under 
local anesthesia. The incision has usually been made in the 
region of McBurney’s point, as the invagination nearly always 
takes place at the ileocecal valve. Most of the cases have been 
reduced by manipulation, even without the use of local anesthesia 
in the mesentery. In the future the mesenteric block, as described 
above, will be used. 

Case Reports Nos. 13788 and 139(31 of intussusception in infants 
demonstrate the practical application of the above. 


Report of Case No. 13788. 

B. N., aged six months, entered hospital May 16, 1920. 

Diagnosis: Intussusception. 

Operation: Laparotomy and reduction of intussusception. 

Anesthesia: Local infiltration. 

History: Breast-fed baby, well-nourished, and perfectly well 
until twelve hours before entering the hospital. During these 
hours the patient had had intermittent abdominal colic and had 
refused to nurse. He was in a stuporous condition during the 
intervals between pains. Three-quarters of an hour before enter¬ 
ing hospital the patient passed considerable blood and mucus per 
rectum. No abdominal tumor could be felt by rectum or by 
abdominal palpation. 

Technic of Anesthesia: An infiltration block was made over 
McBurney’s region, using 30 cc of a 0.7 per cent novocain-adrenalin 
solution. 

Classical McArthur Incision.— The cecum could not be found 
in its normal location. It evidently had not yet rotated. By 
making traction upon the greater omentum after hemisection of 
the right rectus the colon was located and easily brought into the 
wound. It was found greatly thickened and contained a large 

30 


466 


SURGERY OF THE INTESTINES 


amount of invaginated ileum. Pressure upon the distal end of 
the tumor made its reduction easy. The terminal ileum was 
sutured along the wall of the colon to prevent a recurrence. The 
appendix looked angry but was not removed. The portion of 
the bowel that had been invaginated looked extremely dark and 
the baby, who had been very ill at the beginning of the operation, 
showed at this stage considerable shock. Under the application 
of heat, the color of the bowel rapidly improved. The abdomen 
was closed in layers with chromicized catgut. The patient was 
discharged, well, May 23, 1920, one week from date of operation. 

Note .—This baby was operated upon between spasms and made 
no outcry or remonstrance during operation. It is possible that 
the stuporous condition of the infant acted as an aid to the anes¬ 
thesia. Every opportunity was offered, at any rate, for carrying 
out the operation. 

The following case illustrates another phase of the subject: 

Report of Case No. 13961. 

T. YV., aged three months, entered hospital August 19, 1920. 

Diagnosis: Intussusception. 

Operation: Laparotomy and reduction of intussusception. 

Anesthesia: Local infiltration; novocain-adrenalin solution. 

In this case examination showed a tumor mass lying transversely 
across upper abdomen. A classical infiltration block was made 
for the gridiron incision. One end of the tumor presented beneath 
the incision and reduction was made without difficulty. The 
findings were much the same as in Case No. 13788 above. The 
same operative technic was followed and the abdomen closed without 
drainage. 

Note .—Before and during the operation up to the time of the 
reduction of the intussusception this child cried out at short inter¬ 
vals and it was necessary to use great caution in preventing the 
extrusion of small intestine. Immediately after the reduction 
of the intussusception the patient ceased crying, took a drink of 
water and appeared quite comfortable while the operation was 
being completed. The patient was discharged August 26, 1920. 
It was apparent in this case that the child’s remonstrance during 
the operation was due to the spasm of the intestine rather than 
to the operative procedure. The bowel in this case was reached 
without the necessity of making traction and this baby showed 
practically no shock during or after the operation. 

Tuberculous Peritonitis.—In many instances only an infiltration 
of the abdominal wall is required. However, in a number of cases 
resection of the intestine for localized tuberculous disease has been 


TUBERCULOUS PERITONITIS 


467 


performed under infiltration anesthesia with entire satisfaction. 
The condition, as a rule, presents nothing unusual in the technic 
demanded. This technic has been covered in the preceding pages. 

Among the most difficult of these cases which the author has 
been called upon to treat are the following: 


Report of Case No. 7277. 

F. M., aged nineteen years, entered hospital February 1, 1914. 

Diagnosis: Tuberculous peritonitis; tuberculous fistula of the 
intestine. 

Operation: Intestinal resection (multiple). 

Anesthesia: Local infiltration. 

History: Patient had had several intraperitoneal abscesses 
drained in 1913. Finally he developed intestinal obstruction in 
1914, for which an enterostomy was done. At this time the 
adhesions were so dense that it was impossible to find any free 
peritoneal surface, and the author contented himself with an enter¬ 
ostomy which w as made under the use of local anesthesia. On 
February 4, 1914, an attempt was made to excise the fistula and 
close the sinus into the intestine. 

Technic of Anesthesia: 120 cc of a 0.5 of 1 per cent novocain- 
adrenalin solution was used. A circumferential infiltration v r as 
made w r ell away from the site of the old scar, which, with the fistula, 
was then excised. The fistula entered the small intestine, and 
its removal from the loops of surrounding small intestine left two 
rather large denuded peritoneal surfaces. A considerable amount 
of tuberculous granulomatous tissue presented and involved the 
wall of the intestine so that a rather wide excision w-as considered 
advisable. 

The intestine w r as divided and the ends inverted. A lateral 
anastomosis w r as made with catgut. In this case division of the 
bowel caused complaint on the part of the patient, and he also 
complained repeatedly when the needle was inserted through the 
bowel wall, even though traction was avoided. This is the only 
observation of this nature in the author’s experience. (See Perito¬ 
neal Pain Sense). 

Report of Case No. 14392. 

J. P. M., aged forty-four years, entered hospital September 7, 
1921. 

Diagnosis: Tuberculous peritonitis with obstruction; pulmonary 
tuberculosis. 

Operation: Intestinal resection, lateral anastomosis, September 
16, 1921. 


468 


SURGERY OF THE INTESTINES 


Anesthesia: Local infiltration. 

History: Pulmonary tuberculosis for ten years and distress in 
the abdomen for eight years. Three or four weeks ago the patient 
began to have symptoms of obstruction. Examination showed 
a localized tumor in the pelvis. 

Technic of Anesthesia: Local infiltration of abdominal wall 
with 120 cc of 1 per cent novocain-adrenalin solution. 

The general peritoneal cavity was found studded with tubercles. 
About 60 cm. of the ileum were resected, the ends inverted and a 
lateral anastomosis made. An intestinal fistula began discharging 
ten days later but finally closed. The patient left the hospital with 
wounds completely healed in six weeks. His pulmonary condition, 
which was far advanced, grew progressively worse, and he died 
a few months later. 

Note .—The emergency operation was carried out without pro¬ 
ducing any apparent change in the patient’s condition and is 
reported here because it is characteristic of the benign influence of 
the method. 

Intestinal Obstruction from Other Causes.—The management of 
cases of intestinal obstruction will depend greatly upon local condi¬ 
tions. The greatest difficulty is met in the treatment of cases of more 
or less obscure etiology, especially when accompanied by marked 
distention. In case the point of obstruction can be located by the 
examining finger after the abdomen has been opened it may only be 
necessary to deal with the local condition presented. The careful 
introduction of gauze packs and the retraction of the distended 
bowel may suffice to visualize the point of obstruction. Or a loop of 
non-distended gut may be distinguished and the point of obstruc¬ 
tion located by following the collapsed bowel systematically until 
the point of obstruction is reached. This procedure is not diffi¬ 
cult under local anesthesia, provided the bowel is at once returned 
to the abdomen as the next portion of it is withdrawn. However, 
it frequently happens that the operator is confronted by distended 
intestinal coils which can be controlled only with the greatest 
difficulty. While it was formerly the author’s practice to administer 
general anesthesia to these patients as soon as the abdomen was 
opened, he has during recent years departed quite radically from 
this plan. The method recently worked out for the management 
of these cases under local anesthesia is as follows: 

The abdominal wall is opened after the establishment of an 
infiltration anesthesia. The distended intestines are onlv tern- 
porarily restrained while their general condition is ascertained and 
gangrenous bowel is looked for. An effort is also made to obtain 
a loop of collapsed gut, in order to locate the point, and likewise 
the cause, of obstruction, In the event gangrenous bowel is 


TEMPORARY DRAINAGE OF DISTENDED BOWEL 469 


encountered it is allowed to escape through the abdominal incision 
and the operative procedure which seems indicated is carried out. 
1 his can usually be done without the addition of general anesthesia. 

Should only distended intestine present and it be found impossible 
t° locate and treat the cause of the obstruction, the skin of the 
abdominal wall is carefully excluded by means of towels. The 
incision is then surrounded by a rubber sheet upon which the 
distended coils are allowed to lie as they extrude from the peritoneal 
cavity. No restraint is offered to the escaping intestine, and we 
have been gratified to find that the resulting pain experienced by 
the patient is readily tolerated and that, in some instances, there 
is practically no pain accompanying this procedure. With the 
abdomen fairly free of distended intestines it is usually possible 
to locate and remove the cause of the obstruction, provided the 
condition is amenable to relief. 

Following this the surgeon is confronted with the necessity of 
returning to the peritoneal cavity the eviscerated coils of intestine. 
In order to do this without trauma and without the use of general 
anesthesia it is usually necessary to relieve the intestine of its 
distention. The accomplishment of this condition presents decided 
advantages. It permits of the return of the intestines to the 
abdominal cavity without marked pain or distress to the patient, 
and, in addition, removes from the intestinal tract toxic material 
which otherwise has a deleterious effect upon the patient. 

Technic of Temporary Drainage of Distended Bowel—The Rubber 
Towel Method.— The main objection to temporary drainage of the 
intestinal tract is the opportunity offered for septic contamination. 
By adopting the following plan we have reduced to a minimum 
the possibility of infection. A purse-string suture of linen is passed 
through the serous coat of a distended loop of bowel at a point 
opposite the mesentery, and the two ends of this suture are then 
grasped firmly by a hemostat. A large rubber towel is now placed 
over the intestinal coils and the ligature is passed through a small 
perforation near the center of the rubber towel. By this means 
a small knuckle of intestine may be drawn through the rubber 
towel and is easily controlled by means of the purse-string ligature. 
The bowel may now be opened and its contents allowed to escape, 
either with or without the use of a trocar or suction. While the 
surgeon controls the ligature, his assistant, with his hands beneath 
the rubber towel and in contact with the distended intestine, may 
force the contents of the bowel through the drainage opening. 

The septic material will escape down the side of the rubber towel 
into a receptacle. When this procedure is finished the knuckle 
of bowel may be effectually cleansed of septic material by irrigating 
it with salt solution, after which the purse-string ligature may be 


470 


SURGERY OF THE INTESTINES 


tied and severed, allowing the knuckle of bowel to slip out as the 
septic towel is removed. This procedure may be repeated as often 
as one desires until the intestinal tract is completely collapsed. 

Enterostomy.— Should an enterostomy be considered necessary 
one has but to introduce a tube into the open bowel and anchor 
it in position with a ligature. By following this plan the author 
has been able to operate upon all the desperate cases—the cases 
most urgently demanding the use of local anesthesia, without the 
addition of a general anesthetic to the already heavy burden of 
the patient. 

Peritonitis Ileus.— In this class of cases one may be forced to 
meet manv of the same conditions as were enumerated under the 

t/ 

heading of septic peritonitis. When collections of pus are likely 
to be encountered or when there is danger of spreading infection 
the technic laid down on page 484 will be indicated. 

Abscess cavities should be emptied by suction and every effort 
made to prevent further dissemination of the infection. By care¬ 
ful isolation of the infected part and emptying the abscess cavity, 
one may be able to visualize or to palpate the point of obstruction. 
Following the relief of the condition the advantages enumerated 
under septic peritonitis apply. 


CHAPTER XVII. 


local anesthesia in surgery of the 

APPENDIX. 


APPENDICITIS. 

Special Considerations. — Acute or Subacute. —Medical Manage¬ 
ment. —In the management of these cases the prevention of the 
spread of infection beyond its present confines is of the utmost 
importance. The method of preventing the dissemination of 
intraperitoneal infection in the absence of operation is not germane 
to this discussion, but its relation to local anesthesia in the event 
of surgical interference is exceedingly important. 

Surgical Management.— Once operation is decided upon, there 
are three periods during which the management of a case may 
greatly influence the outcome. The first period, extends from the 
time that the operation is decided upon until the operation is 
begun. The second period extends from the time the operation 
is begun until it is completed and the third period extends from 
the time the operation is completed until convalescence is 
established. 

Preoperative Management. —During the first period the great 
danger of the spread of infection is from rough or careless handling 
of the patient or from struggling incident to the induction of general 
anesthesia. The author has personal knowledge of 6 instances 
in which localized intraperitoneal collections of pus were dis¬ 
seminated as a result of the rupture of the abscess wall during the 
first period, as designated above. In 2 instances the careless lift¬ 
ing of the patient produced a rupture and in 4 the struggling of the 
patient during the excitement stage of the induction of general 
anesthesia resulted in this disaster. It would seem, therefore, that 
too much stress could not be laid upon the necessity for the utmost 
care in transporting such patients from the bed to the operating 
table. Furthermore, there seems to be no denying the fact that 
the struggling incident to the induction of general anesthesia 
must be recognized as a possible source of danger. 

Operative Management.— The danger of disseminating localized 
infective processes during the second stage should, it seems, be 
more clearly recognized. The necessity of obtaining a silent 
field and reducing the respiratory excursion of the intestines, 
caused by strenuous breathing, struggling, retching or vomiting, 


472 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX 


should be more universally recognized. Cognizance should also 
be had of the fact that one’s most careful endeavors to prevent 
the dissemination of infection in the peritoneal cavity by the per¬ 
formance of the operation without soiling may be too often negatived 
by the intestinal turmoil which results within the abdomen from 
vomiting after the completion of a careful operation under general 
anesthesia. Every effort should be made to prevent the non- 
adherent coils of intestine from entering the infected field, after, 
as well as during, operation. It is good practice to use the greater 
omentum, wherever possible, to prevent this undesirable occurrence. 
The prevention of vomiting and visceral turmoil are more important, 
however. 

Effect of Anesthesia upon Postoperative Course.— Postoperative 
retching and vomiting and careless handling of the patient, com¬ 
bined with bodily activity of the patient during his recovery from 
the effects of general anesthesia, are the most common causes of 
the dissemination of infective material during the third stage. 
I pon a number of occasions opportunities have presented to 
establish the fact that following abdominal operations under local 
anesthesia the different organs remain in approximately the same 
relative position as that in which they were left, provided the 
patient has been carefully transported back to bed and has not 
vomited. Conversely, the author has had occasion to record, in a 
number of instances, where it was necessary to reopen the abdomen 
after an operation which had been performed under general anes¬ 
thesia, that a great excursion had taken place in many of the 
organs, notably the cecum, the transverse colon, the sigmoid, 
the stomach and the greater omentum. It is believed that in the 
management of peritoneal suppurations there exists one of the 
most important advantages of local over general anesthesia. 

Position upon the Operating Table. —The table is equipped as 
for Trendelenburg cases (Fig. 1, page 84), and in addition a support 
is placed at the left side (Fig. 1, B). Before beginning the infil¬ 
tration a moderate Trendelenburg and a left lateral tilt is assumed 
(Fig. 202). 

Incisions. —Recurrent Appendicitis.—The choice of an incision for 
the removal of the chronic appendix has very little bearing upon 
the local anesthesia problem. However, as a rule the McArthur 
gridiron incision may be said to be the one of choice, and, as in the 
author’s practice it is used almost universally, the technic detailed 
will relate especially to this incision. The anesthesia technic for 
the other incisions may be easily deduced from the description 
given. (Fig. 203, A, B , and C.) One may, provided more room 
is required, divide the sheath of the rectus. The incision of Elliott 
is an excellent one when additional exposure is required. 


APPENDICITIS 


473 


The Transverse Abdominal Incision. 1 —“In the Boston Medical and 
Surgical Journal , March 29, 189(5, J. W. Elliott published a des¬ 
cription of a modification of the McBurney incision for appen- 
dicectomy. A. E. Hockey of Portland, Ore., in the Medical Record, 


Blood 


pressure 
u&rd J 


R.&rm re 



Lateral 
£> upport 


arm rest 






1 

A 

\ 


/ 


Fig. 202. —Appendicectomy. Transverse section of body at appendix level show¬ 
ing lateral tilt, vertical retraction, negative pressure and exposure. A, long rubber- 
typed forceps; C, cecum. 

July-December, 1905, strongly recommended the transverse 
incision for work in the lower abdomen and called attention to the 
satisfaction with which the appendix could be removed through 
this incision. In January, 1906, Gwilym 0. Davis of Philadelphia 

1 Farr, R. E.: Am. Jour. Surg., September, 1915. 





















474 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX 


once more described this incision in the Annals of Surgery. Boeck- 
man of St. Paul, in the St. Paul Medical Journal , June 2, 1910, 
also called attention to this incision, for which he had also been 
given credit by Charles F. Denny in the Boston Medical and Surgical 
Journal, June 3, 1909. Although Boeckman worked out this 
incision independently and without knowing that it had been 
used before, he gives Elliott the credit for having first described it. 

“Having been, since 1910, an ardent advocate of the transverse 
abdominal incision for all work in the upper abdomen, not excepting 
that upon the kidney and spleen, it took but a few trials of the 



Fig. 203.—Appendicectomy. Anesthesia technic. A, B, C, subdermal infiltration 
and infiltration block. Insert : sectional view of same. 


Elliott incision to convince the author that it was by all odds the 
most satisfactory incision for cases in which the so-called gridiron 
incision of McArthur is ordinarily used, and even for the cases 
in which the modifications recommended by Wier and Harrington 
are employed. In a certain percentage of cases bad results follow 
the incision recommended by Battle 2 , Jalaguier, 3 Kammerer, 4 
Lennander 5 , and Edebohls. 6 Even where primary healing takes 
place it is probable that these bad results are due directly to 


2 British Med. Jour., 1895. 
4 Centralbl. f. Chir., 1898. 

6 Med. Rec., 1899. 


3 Ann. Surg., 1897. 

5 Ann. Am. Surg., 1899. 




































Appendicitis 


475 


nu \ e injury. As the nerves to the rectus muscle enter at right 
angles, am \ ertical incision must necessarily interrupt their 
continuity. 1 he only reason for making any incision other than 
the gridiron is on account of the necessity for more room through 
which to carry out the operative procedure. 

With the incision of Elliott ample space may be obtained. Being 
nearly transverse, it severs the fibers of the external oblique in a 
diagonal diiection. Although Boeckman states that these fibers 
aie subsequently under some tension when closing the wound, 
such has not been the author s experience. He has found it possible 
in all cases to imbricate the layers with mattress sutures. 



Fig. 204.—Appendicectomy. Elliott incision showing muscle layers. 


“By continuing the incision to the midline and stripping the 
aponeurosis from the right rectus, this muscle may be retracted 
to the midline, and in this way an incision 8 to 10 cm. in length 
may be obtained. The incision may be made at the level of the 
umbilicus or a few centimeters below, depending upon the pathology 
one expects to encounter. In case drainage is necessary, it is a 
good rule here, as in other localities where abdominal drainage 
is necessary, to provide a separate stab wound and to close the 
original incision, excepting in cases where one must of necessity 
leave the original wound open. But one hernia has followed in 
the author’s cases, and this was in a case of suppurative appendi¬ 
citis in a physician whose extensive drainage was carried out 








476 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX 


through the outer angle of the wound. As most of this work has 
been done under local anesthesia for over fifteen years, the method 
has been given a very severe test. 

“With this incision and vertical retraction, and the patient rotated 
to the left 30 or 40 degrees, we have been able to see, in most cases, 
the appendix lying in its natural position and in some cases we 
have been able to anesthetize the mesoappendix before liberating it 
from adhesions. 

“The following points of excellence may be mentioned: Sufficient 
room, conservation of nerve and blood supply and the cosmetic 
result of closure. Figs. 204 and 205 illustrate the above-mentioned 
incision.” 



Fig. 205.—Appendicectomy. Elliott incision opening into abdominal cavity 

completed. 

TECHNIC OF SUBDERMAL INFILTRATION. 

An initial wheal is made at a point at least two cm. external to 
the point where the proposed site of the transverse incision is to 
begin and a subdermal infiltration outlines the proposed site of the 
incision, going well over toward the midline. (Fig. 203, A and B, 
also insert A', B ', C'.) 

TECHNIC OF DEEP INFILTRATION. 

The needle is now introduced through the initial wheal (Fig. 
203, A), in the direction of the loin, that is, backward and outward, 




TECHNIC OF DEEP INFILTRATION 


477 


until it is felt to pierce the external oblique. This layer is readily 
recognized and even the spectators may note the slight jerk as it 
is pierced, the muscle usually contracting slightly as it resents 
the intrusion of the needle. Again, the patient may show signs 
of pain or distress if one happens to pierce a large sensory branch 
during this procedure. This contingency should be anticipated 
in every instance and the patient warned that he may feel some 
pain. The slight twinge will thus become an aid to the surgeon 
rather than a menace, as it may be if the patient has been 
assured that he will feel nothing and then finds himself in disagree¬ 
ment with the surgeon. Even asking the patient whether he feels 
the needle is less satisfactory than the above method, as it is apt 
to suggest to his mind the possibility: that there is some question in 
the surgeon’s mind about the result expected, and this may be a 
factor in decreasing the confidence of the patient. As soon as the 
external oblique is pierced approximately 15 cc are injected between 
this structure and the internal oblique and the needle is then carried 
down to the peritoneum, the fluid always being injected in advance. 
(Fig. 203, Insert A', IV , C'.) We have found that this maneuver 
has the effect of “ floating” the peritoneum ahead of the needle point 
and that the chances of piercing this structure are greatly reduced 
thereby. However, the introduction of the needle through the 
peritoneum is without danger provided it is done carefully. When 
approaching this layer the needle should be advanced slowly. A 
wall of infiltration block is now made at right angles to the line of 
the incision, its midpoint corresponding to the initial wheal. This 
is done by introducing the needle through the external oblique 
and is not usually noticed by the patient or his muscles. In case, 
however, there is the slightest evidence of a sensory nerve response 
this signal calls for the deposit of a more liberal supply of the 
anesthetic at this point. In fact, a slight response is often desirable 
as it shows the surgeon the points at which a more generous supply 
of the solution is demanded. After this block of the nerves is 
made, the deeper tissues along the course of the proposed incision 
are infiltrated. This injection is made in a measured, methodical 
manner, beginning at the outer end of the line and building a wall 
of anesthesia along it. This wall should be rhomboid in shape on 
cross-section and the base should be about 5 cm. wide. Each 
introduction of the needle will cover a certain area, depending 
upon the size of the needle, the force of the fluid, the resistance of 
the tissues and the speed at which the needle is advanced. Expe¬ 
rience soon teaches one the art of thoroughly covering the field. 
Usually the needle is introduced vertically at first, then with¬ 
drawn until the point is disengaged from the aponeurosis and then 
reinserted through the deep tissues to the right and then to the 


478 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX 


left of the central area. This procedure is repeated at intervals 
until the proposed line of incision is covered. It is advisable to 
use a smaller amount of the solution proportionately as the mesial 
end of the incision is approached, as this area is apt to be already 
anesthetized from the effect of the solution previously injected. 
Using the above technic, the introduction of the anesthetic requires 
from two to five minutes, depending upon the thickness of the 
abdominal wall, the length of the incision, and, more especially, 
upon the mental attitude of the patient. The sensitive or appre¬ 
hensive patient cannot be injected as rapidly as can the phlegmatic, 
stoical individual. Again, the patient who adopts an attitude of 
skepticism regarding the method—one who has to be “shown” 
before he will be convinced—cannot be infiltrated as rapidly as can 
the one who, through experience or education, has confidence that 
the method will succeed. In a large number of cases perfect anes¬ 
thesia of the abdominal wall has been established in less than two 
minutes and the skin incision made in three. With the proper 
equipment and the above detailed technic the time required for 
anesthetizing the abdominal wall, even in the most nervous cases, 
is negligible. GO to 90 cc of the solution is the average amount 
required. 

Technic of Opening the Abdomen.—The incision is made between 
towel pins which elevate the skin (Fig. 212, page 490), and in this 
manner the possibility of distress from pressure is eliminated. 
The abdominal cavity is approached with the greatest possible 
care, the different layers of the abdominal wall being retracted 
vertically before being incised (Fig. 213, page 491). Provided now 
that good anesthesia has been established we may expect to find 
a negative intra-abdominal pressure, an inrush of air as the peri¬ 
toneum is incised and all small intestines carried well to the left 
and toward the upper abdomen by the force of gravity. Thus 
the intestine, instead of protruding through the incision, as is so 
frequently seen under general anesthesia unless it is very deep, 
fall away from the incision, allowing the surgeon a view of the 
local conditions as they exist. (Fig. 202, page 473.) If carefully 
performed retraction may be made with some force when found 
necessary, but, as a rule, a low gridiron incision will show some 
portion of the appendix directly in the field. Since using this 
technic in every case, generally without the introduction of gauze 
packs or the use of general anesthesia, the author has been able 
to locate the appendix no matter how obscure its position might be. 
One should not hesitate to enlarge the wound by further incision or 
by careful stretching with the fingers when it is necessary. 

Technic of Meso-appendix 0. T. Infiltration.—As soon as the appendix 
is located it is lightly held by tissue forceps while the point of the 


TECHNIC OF DEEP INFILTRATION 


479 


needle is engaged beneath the peritoneal coat of the meso-appendix 
O. T. (b ig. 20(3). 1 he structure is then ballooned up with the novo¬ 

cain-adrenalin solution before being secured by an artery forceps. 



Fig. 206.—Appendiceetomy. Anesthetizing the meso-appendix O. T. 


Technic of Delivering Appendix.—If the appendix can now be 

delivered it is removed by the usual technic but otherwise the 
retaining structures are dealt with. Often we find that a division 
of the meso-appendix will allow the delivery of the organ. Again, 
adhesions or congenital bands or perhaps a lack of correspondence 
between the position of the appendix and the location of the abdo¬ 
minal incision may make it impossible to accomplish the removal 
outside of the abdomen. In this event no untoward destruction 
of the attachments of the cecum is called for and no undue traction 
should be made upon the cecum, but the work should be done 
within the abdomen, which is quite as simple a procedure as is the 
usual one. A curved needle held by a needle holder is substituted 
for the conventional straight needle, and by using the forceps tie 
(Figs. 32, 33 and 34, page 155), no difficulty will be encountered. The 
point of utmost importance is that strategy must be employed in 
order to obviate the necessity for the use of the dreaded traction. 
The following case well illustrates some of the difficulties encountered 
and the manner of dealing with them. 


Record of Case No. 8505. 

W. O. A., aged twenty years, entered the hospital January 6, 

191 7 . 

Diagnosis: Subacute appendicitis, 

Operation: Appendiceetomy. 


480 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX 


History: The patient was first seen in 1914 when he presented 
a history of right-sided abdominal pain during the previous year, 
but examination at that time showed a normal temperature and 
no tenderness or rigidity. January 2, 1917, he again reported 
stating that he had been free from pain during the past three years, 
but during the night it had begun suddenly, awakening him, and 
was most severe in the region of and to the right of the umbilicus. 
Nausea began six hours after onset while on a street car and 
was not accompanied by vomiting. The pain was intermittent 


in character. 

Anesthesia: Local infiltration block. 

The technic as shown in Fig. 203, page 474 was used in making 
the abdominal infiltration, using 150 cc of a 0.7 per cent novocain- 
adrenalin solution. 

A McArthur incision was made and very gentle retraction 
was employed. The appendix was long and subperitoneal dis¬ 
section for about 15 cm. was necessary in its removal, base first — 
following the technic of anesthesia described (Fig. 207, page 483). 
Traction on the appendix and meso-appendix gave pain identical 
with that during his attacks and also induced vomiting. Removal 
and closure were done in the usual manner. 

Note .—The patient’s postoperative convalescence was com¬ 
plicated by urinary retention which, however, may have been due 
to specific urethritis, and he left the hospital one week after 
admission. 


APPENDICECTOMY UNDER VARYING CONDITIONS. 

Acute Appendicitis.— While most surgeons are perhaps willing to 
admit that the removal of the interval appendix can be accomplished 
painlessly under local anesthesia, and while many surgeons perform 
occasional appendicectomies under this method, it is generally 
considered unsatisfactory in cases of acute disease of this organ, 
either before or after rupture, and especially so in abscess cases. 
The author’s experience with local anesthesia in these cases is so 
at variance with the above premise that he can only reiterate what 
he has so often stated when writing or speaking upon this subject. 
He believes that there is much less reason for the removal of the 
interval appendix under local anesthesia than for the handling of 
acute or subacute conditions by this method. In the former it 
is more a question of comfort, although it must be admitted that 
it decreases the liability to complications, lowers the morbidity 
and lessens the dangers generally; while in the latter its advantages 
are manifest regarding the points just mentioned, and with relation 


APPENDICECTOMY UNDER VARYING CONDITIONS 481 


to the last point the advantage is so obvious that no argument 
should be necessary. 

Here, again, the point of contention relates to the possibility of 
doing this class of work under local anesthesia without too much 
discomfort to the patient and with satisfaction to the surgeon. 
That this work may be done with satisfaction in a large percentage 
of cases is true, and the different types to be met will be dealt 
with somewhat in detail even at the risk of repeating matter which 
is undoubtedly well known to many of my readers. The diversity 
of opinion and the many questions of an elementary nature which 
have been asked concerning this particular subject, as well as its 
unquestioned importance, seem to make it well worth careful 
consideration. 

Abdominal Infiltration and Muscular Relaxation.—In acute abdo¬ 
minal conditions blocking the thoracic nerves gives relaxation of 
the abdominal muscles, although perhaps not to the extent seen in 
chronic conditions. However, one frequently sees abdominal 
rigidity disappear to a marked degree immediately after the block¬ 
ing is done, even though sedatives are not used. In a case 
of perforated gastric ulcer, for instance, a bilateral regional 
block brought relief of the muscle spasm and comfort to the patient 
at once, where \ gr. of morphine given some hours before had been 
found unavailing. The accomplishment of this effect, subsequent 
to the blocking of the nerves of the abdominal wall, is an important 
factor in the handling of cases of acute abdominal disease, and 
while the operation in acute cases is by no means as simple a pro¬ 
cedure as in the interval case, it is nevertheless perfectly feasible 
in the vast majority of cases, and in a fair percentage proves to 
be so simple that it is a worthy rival of the interval operation 
in simplicity. It is agreed that the organs in the region of the 
appendix in the acute case should be manipulated and displaced as 
little as possible, and, in assuring this ideal condition, local anes¬ 
thesia is excellent. Its special advantages will be touched upon as 
the different conditions are considered. 

The technic used for entering the abdomen is the same in acute 
cases as for the interval type, except that perhaps more scrupulous 
care is used to prevent pressure upon the tender abdominal wall. 
Upward or vertical traction while incising and after opening the 
abdominal wall is a prime essential to success. Once the abdomen 
is opened we are confronted by one of two conditions. The abdo¬ 
minal cavity may show the intestines in a state of collapse with 
negative intra-abdominal pressure, in which case the appendix 
can at once be seen and dealt with by the technic described for 
dealing with the interval case; or, marked distention may be present 
with a positive intra-abdominal pressure, such as is seen when an 
31 


482 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX 


imperfect anesthetization of the abdominal wall has been made. 
The mistake which is usually made when this condition is met is 
to attempt to locate and remove the appendix without first getting 
a view of the local condition. 

Technic of Delivering an Acute Appendix.—A perfectly free appendix 
may be brought up with little difficulty but an adherent one should 
not be attacked by the method used when the patient is under 
general anesthesia. Possibly the best plan to follow when one 
has ascertained that an acutely inflamed appendix is adherent, is 
to administer nitrous oxide and oxygen while the organ is being 
liberated and then complete the operation under local anesthesia. 
The author has thought it best to handle a number in this manner. 
However, increased experience has taught that many of these 
cases can be done under local anesthesia alone with almost no 
distress. In some cases careful palpation in the dark has been 
rewarded by finding the appendix free and easily delivered. If 
it does not appear after the most simple and painless manipulation 
the saline gauze pack is resorted to and direct vision depended 
upon. The cecum should, as a rule, not be delivered. In inserting 
the packs pain wall not be produced provided proper precautions 
are observed. The abdominal wall should be elevated by a smooth 
metal retractor (Fig. 14, page 101, and Fig. 170, page 396), and 
long narrow saline gauze packs inserted only a short distance into 
the abdominal cavity. A wall of gauze is built above, mesial to 
and below 7 the incision, and thus two purposes are served. The 
cavity is protected to some extent from future soiling and the 
small intestines are controlled. Retractors of appropriate length 
are now used to expose the cecum at the ileocecal valve. The 
mesial aspect may be first inspected and in case this does not 
reveal the offending organ another small pack may be laid over 
the cecum, provided it is distended and has a tendency to pro¬ 
trude, or it may be forced out of the field mesially by the rubber- 
tipped thumbs. This search should be painless or nearly so, if 
done methodically and with care, and should result in locating the 
appendix. Once any portion of the organ is seen local anesthesia 
is freely used in the tissues surrounding it (Fig. 207). In case the 
organ is intact it can usually be freed under this technic with little 
or no distress to the patient. Even in the presence of a localized 
abscess or omental wrapping this technic gives satisfactory results. 
Once freed, it may be removed by the usual technic; in case dense 
adhesions are encountered or if the patient is extremely sensitive, 
or if any other difficulty arises the operation may be temporarily 
interrupted and ether or nitrous oxide and oxygen administered. 
These patients should not be compelled to suffer pain; a nitrous 
oxide analgesia may be produced very quickly in these cases, and as 


APPENDICECTOMY UNDER VARYING CONDITIONS 483 



Fig. 207.—Appendicectomy. Anesthesia technic. The adherent appendix. 






484 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX 


soon as the appendix is liberated may be discontinued. Since we 
have developed the technic for the more perfect exposure we find 
anesthesia by inhalation necessary only in rare instances and 
principally in the cases where the appendix is adherent in the 
pelvis or at some point distant from the incision. Should traction 
upon the cecum be found necessary its mesentery may be anesthe¬ 
tized (Fig. 208) from within or by introducing the needle through 
the abdominal wall just beyond the external lateral angle of the 
incision, or by following around any presenting abscess mass by 
a retroperitoneal infiltration under direct vision, through the 
abdominal incision. 


INTRA-ABDOMINAL ABSCESS. 

Technic fer Drainage.—In cases in which the general peritoneal 
cavity is opened first the technic does not differ materially from that 
which is to be recommended for operation in acute appendicitis. 
The abdominal packs should be more massive and should be so 
placed as to protect the general cavity, although, on account of 
the absence of straining, the danger from soiling is much reduced 
when local instead of general anesthesia is employed. After plac¬ 
ing the packs it may be found advisable to administer general 
anesthesia for the critical portion of the operation. However, it 
has been found that with a good exposure and a liberal infiltration 
of the tissues about the viscero-parietal union, which must be 
broken up in order to open the abscess, these cases may be handled 
without difficulty. The appendix, when found, is dealt with in 
much the same manner as in other abscess cases. It is significant 
that this organ is being found and removed in a vastly higher per¬ 
centage of abscess cases than was the case when general anesthesia 
alone was used and speed was the main objective. In removing 
the packs after placing the drains some strategy is necessary. 
The abdominal wall should be elevated and the packs removed 
in order inversely to that in which they were inserted. In this 
way, even after very extensive coffer-damming has been done, 
the gauze may be removed without pain. 

Even in children this technic has been employed with satis¬ 
faction. 

Report of Case No. 10758. 


M. I). B., aged seven years, entered hospital July 21, 1920. 
Diagnosis: Acute appendicitis. 

Operation: Appendicectomy. 

History: The patient had been sick twelve hours with appendi¬ 
citis. 


INTRA-ABDOMINAL ABSCESS 


485 


7 echnic of Anesthesia: Local infiltration, GO cc of a 1 per cent 
novocain-adrenalin solution being used. 

1 he abdomen was opened under perfect negative pressure, a 
large indurated appendix was seen lying mesial to the cecum, the 
mesoappendix was infiltrated before elevating the organ and was 
then removed in the usual manner. Fig. 209 shows the patient 
during the operation and depicts graphically the mental attitude 
of the child. 

Note .—This patient’s sister had been operated on March 10, 
1920, for acute appendicitis, and the patient insisted that she 
wanted her operation with the same kind of anesthesia. 



Fig. 209.—Appendicectomy. Photograph of Case No. 10758, aged seven years, 

during operation. 


Report of Case No. 13910. 

E. D. G., aged three years, entered the hospital April 17, 1917. 

Diagnosis: Acute appendicitis with abscess. 

Operation: Appendicectomy with drainage. 

Anesthesia: Local infiltration, 75 cc of a 0.5 of 1 per cent novocain- 
adrenalin solution, was employed. 

Anesthesia was established by infiltration method and restraint 
of the patient was unnecessary. The McArthur incision was 
used and the free peritoneal cavity opened with negative pressure 
(Fig. 210). The free peritoneal cavity was then carefully packed 
off with narrow, moist sponges. The parietal peritoneum was 
infiltrated and the cecum was carefully separated from the abdominal 
wall. 180 cc of pus were evacuated by suction. Light was reflected 
into the abscess cavity and the appendix could be seen projecting 
from the floor of the abscess wall. It was removed subperitoneally, 
a catgut ligature being placed around its base. Two cigarette 
drains were inserted. The omentum which followed the removal 
of the protective packs was placed about the drains and the abdo¬ 
men partially closed. 






486 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX 


Note .—The child made no complaint throughout the operation, 
she had no postoperative nausea or vomiting, and although the 
temperature rose to 104° the day following the operation and the 
pulse became thready, she made an uneventful recovery. 



Fig. 210.—Appendicectomy. Photograph of Case No. 13910, aged three years, 

during operation. 

SUPERFICIAL ABSCESS. 

Technic for Drainage.—One of the simplest conditions, and one 
which it seems should seldom require general anesthesia, is the 
opening of an appendiceal abscess which communicates directly 
with the parietal peritoneum. Simple infiltration of the abdominal 
wall is all that is necessary. The incision can then be made between 
towel pins, thus eliminating pressure pain, and the pus is evacuated, 
preferably by suction. Once the abscess is completely emptied 
a careful search may show some portion of the appendix projecting 
into the cavity or forming a portion of the abscess wall. One is 
frequently able to remove the appendix in these cases. As a rule 
no effort is made to invert the stump and generally ligatures are 
omitted. A clamp is usually placed upon the appendix before its 
removal and this is allowed to remain in situ for a few days. Oper¬ 
ations upon these cases under local anesthesia are well-nigh ideal 
in every way, the pain is negligible and the patient’s energy is con¬ 
served to the fullest possible degree. Locally the exposure is per¬ 
fect, the tissues remain quiet and the necessity for haste is elimi¬ 
nated. Furthermore, the absence of marked manipulation during 
operation and vomiting after operation are desirable attributes. 



THE APPENDIX AND PELVIS 


487 


THE APPENDIX AND PELVIS. 

Special Considerations.—In doing pelvic work under local anes¬ 
thesia the appendix can be reached with ease through the midline 
incision provided a negative pressure is obtained. The relaxation 
of the abdominal muscles will usually allow the cecum to drift 
above the pelvic brim, and often it will travel into the right loin 
and well out of view. A ertical retraction of the upper right hand 
corner of the incision with a smooth, stout retractor of the type 
shown in Fig. 14, page 101, will allow one to see the cecum and 
generally the appendix also. By means of the rubber-tipped for¬ 
ceps (Fig. 2(3, page 110) it may be brought down and often out of 
the abdomen if so desired. The base of the appendix is seldom 
found buried and as soon as seen may be steadied while the meso- 
appendix is infiltrated. (See Fig. 206, page 479.) In case the 
appendix is retrocecal the peritoneum should be blocked before 
incising. (Fig. 208, page 483.) In doing work under local anes¬ 
thesia the appendix should be freed by sharp dissection rather 
than by tearing the adhesions, and only sufficient force should be 
used to identify the bands when using traction. Severe or even 
moderate traction upon the appendix or cecum is prone to cause 
nausea and vomiting and this accident, which is exceedingly dis¬ 
tressing to the patient, has the great disadvantage of changing the 
whole aspect of the procedure. One expulsive effort will usually 
be sufficient to project coils of small intestine into the field and 
often out upon the abdominal wall. The result of this occurrence 
is obvious. The pain resulting from the traction upon the mesentery 
of one or more coils of intestine thrown out may be severe. This 
traction may also serve to increase the nausea and cause further 
vomiting. The pain produced by restraint of the protruding 
intestine is often severe and the damage which results from gauze 
pressure against the sensitive serosa covering it will likely mani¬ 
fest itself during the convalescence by distention and gas pains. 
Furthermore, the sudden occurrence of vomiting, provided it 
happens at a critical time, may in certain instances result in the 
spread of infective material. The interference with the technic 
of the operation and the forcing of the operator to complete the 
work under general anesthesia is not the least distressing feature 
of this accident. The hazard of vomiting is considered so important 
that it should be placed before pain as a contraindication of local 
anesthesia in abdominal surgery, and yet it does not often occur. 
When it does occur, it is usually due to some overt act on the part 
of the surgical team, and it may be so sudden in its onset that the 
damage is already done before one realizes its onset. In another 
chapter the question of nausea and vomiting and their prevention 


488 LOCAL ANESTHESIA IN SURGERY OF THE APPENDIX 


has been more minutely considered, but I wish to reiterate some 
of the text here, as traction upon this portion of the intestinal tract 
is especially apt to cause trouble. On account of the danger of 
vomiting, it may be considered desirable to the surgeon to complete 
the pelvic work before the removal of the appendix in some cases. 
In this manner we avoid precipitating the small intestines into the 
pelvis. 

Position upon Operating Table.— Tilting of the table to the left 

(Fig. 202, page 473, Fig. 161, page 384) is one more important aid 
to the gaining of a good view of the appendix, cecum and terminal 
ileum when doing pelvic work. When operating under local anes¬ 
thesia this position is especially desirable. Tables that cannot 
be tilted may be equipped with pillows and sandbags so as to 
approximate the same result, but in no other condition can the 
advantage of attention to details which may seem trivial be better 
displayed than in locating and delivering an appendix by the aid 
of a change to or from the Trendelenburg accompanied by a tilting 
to the left while the assistant at the same time carefully raises the 
right upper portion of the incision. These maneuvers will almost 
always show the cecum and appendix. By changing the patient’s 
posture alone it is often possible to bring this structure into the 
field and thus to avoid the traction which may be so undesirable in 
its results and which by the use of strategy may be made unneces¬ 
sary. This change of position or tilting should be made without 
active muscular effort on the part of the patient so that the negative 
pressure may not be overcome. As a rule, when both pelvic work 
and appendicectomy are to be done, the pelvic blocking is made as 
soon as the abdomen is opened and before the appendix is removed. 
The delay thus necessitated allows time for thorough dissemination 
of the fluid used in the pelvic block and thus the maximum effect 
of the drug is assured. However, if the appendix is not free, it 
may be well to reverse this procedure for the aforementioned 
reasons. 


CHAPTER XVIII. 

LOCAL ANESTHESIA IN SURGERY OF THE PELVIS. 


Pelvic Blocking.— The most sensitive structure with which we 
must deal in the pelvis is the round ligament and, fortunately, 
this is easily anesthetized. The ovarian pedicle is sensitive, as 
is also the peritoneum covering the cul-de-sac. All work in the 
pelvic region is best done with the patient in the Trendelenburg 
position, and it is desirable that the position be assumed several 
minutes before the anesthetic is injected, and that when in this 
position the patient be at ease and comfortable. The accessories 
described in Fig. 1, page 84, are valuable adjuncts in obtaining 
the desired comfort. Soft pillows, pneumatic cushions for the 
shoulders, metal legholders, which restrain but do not constrict, 
the avoidance of too sharp flexion at the knee (which, with an exten¬ 
sion of the head upon the neck, greatly increases muscular resistance 
of the abdominal wall) and a careful adjustment of the drapes, 
all tend to facilitate work in this region. While attention to these 
details may seem unimportant, success can only follow such attention 
and he who is not willing to pay heed to the smallest detail and 
does not recognize the prime essentials—of which the patient’s 
comfort is one of the most important—will continue to bore one 
with the criticism that local anesthesia is unsatisfactory in pelvic 
surgery, and advise the use of spinal or general anesthesia. 

Skin Sterilization.— The greatest care should be exercised that 
irritating solutions used for sterilizing the skin be not allowed to 
trickle down between the thighs or reach the external genitalia. 
This every-day occurrence during general anesthesia cannot be 
allowed when using local anesthesia and similar intolerable accidents 
can only be avoided by the constant vigilance of everyone connected 
with the care of the patient. 

Incisions for Pelvic Operations.— The author employs the ver¬ 
tical incision, as a rule, though that of Pfannenstiel has been used 
in a fair percentage of cases. The anesthesia is introduced with 
the patient in the Trendelenburg position and in the manner shown 
in Fig. 211, and vertical retraction of the abdominal wall is insisted 
upon during the whole period in which the incision is being made 
(Fig. 212). 

Exposure. —After the abdomen has been opened by an incision 
which is liberal in its proportions, a negative pressure should be 



' 




Fig. 211.—Abdominal incision. Anesthesia technic; infiltration. 

view of same. 


Insert: sectional 



Fig. 212. —Abdominal incision. Incision between towel pins making vertical 

retraction. Insert: sectional view of same. 















EXPOSURE 


491 


piesent. Retraction should be made in a vertical as well as a 
lateral direction, and should he of the elastic gradual type (Figs. 213 
a nd 214), that is, at right angles to the plane of the abdominal wall and 
the upper or umbilical end of the incision should be elevated first, 
this increases the capacity of the upper abdominal cavity and 
generally the force of gravity alone will cause all small intestines 
to migrate above the pelvic brim (Fig. 215). In case this ideal 





Peritoneum 


Fig. 213.—Abdominal incision. Exposure while making same. 


condition does not prevail and some coils of intestine remain in 
the pelvis they may generally be picked out and allowed to fall 
to the upper abdomen by means of the rubber-tipped thumb for¬ 
ceps (Fig. 26, page 110). Even though in some instances a fairly 
large amount of the small intestine hangs over the pelvic brim, 
this may not materially interfere with the performance of the more 
simple pelvic operations such as suspensions, appendicectomies and 








492 LOCAL ANESTHESIA IN SURGERY OF THE PELVIS 


the like. The retraction must be carefully made and the force 
used must be so graduated as to prevent any sudden jerky lifting 
of the abdominal wall, as this is apt to prove painful to the patient 
and to cause the much dreaded expulsive effort. As a rule, no 
sponges are introduced either for the purpose of transferring the 
intestines from the pelvis to the upper abdomen or for the purpose 
of holding them in that position. Under ideal conditions sponges 



Fig. 214.—Exposure of pelvic organs by means of elastic retraction. 


are not necessary and generally the only reason for using them is 
to prevent soiling. They may be used if necessary. 

Adjuncts to Pelvic Operations.— After experiencing some of the 
difficulties which are apt to beset one in attempting to handle 
complicated pelvic cases under local anesthesia, the fact becomes 
evident that if one expects to do this work without administering 
general anesthesia during some stage of the operation, some adjunct 






ADJUNCTS TO PELVIC OPERATIONS 


493 


must be developed as an aid in carrying us through the critical 
portions of the operation—the portion which is found to cause 
distress in a certain percentage of cases. Few methods have been 
tried out that have proved entirely satisfactory. One method 
which is considered in Chapter III, relates to the use of rather 
large doses of preliminary hypodermics (narco-local anesthesia). 
(Pages 72 and 132.) As stated, this form of anesthesia is ideal for 



Fig. 215.—Pelvis (exposure). Sagittal view; vertical retraction; negative pressure. 


almost any surgical procedure one may be called upon to do. Its 
main drawback is its alleged danger and one must await more 
extended use of the method as well as a more careful checking of 
reports upon its dosage and use before a final verdict is given. 

The second method is that of preceding the local infiltration with 
sacral anesthesia (Fig. 28, page 117). The analgesia resulting from 
the introduction of novocain-adrenalin into the sacral canal is 
often sufficient, especially with the patient in the Trendelenburg 
position, to allow one to make free dissections in the pelvis. 

Trans-sacral anesthesia as a preliminary to pelvic laparotomies 
will also offer one an opportunity in a certain percentage of cases 
to carry out extensive pelvic operations. 

Parasacral anesthesia will, according to Braun, give sufficient 
anesthesia of the pelvic organs so that in addition to it one needs 
only to anesthetize the abdominal wall. The writer’s experience 
with this form of anesthesia is limited. With regard to the latter 
two methods he feels that their use will be somewhat limited in 
























494 LOCAL ANESTHESIA IN SURGERY OF THE PELVIS 


the hands of general surgeons, as the technic of their establishment 
is more or less complicated. 

A fifth method and one which offers the great advantage of 
simplicity and ease of application is the injection of the anesthetic 
solution through the vaginal vault as a preliminary to abdominal 
pelvic work. This method is described in Chapter X. We have 
found it especially efficacious in the case of large fibroid tumors 
in which it was difficult to obtain an exposure from above before 
removing the tumor. It should not be used in the presence of 
pelvic infections. 



Fig. 216.—Anesthesia_technic; anterior pelvic splanchnic anesthesia blocking 

round ligament. 

TECHNIC OF INTRA-ABDOMINAL PELVIC INFILTRATION 

AND BLOCKING. 

Anterior Splanchnic Anesthesia.—The first point to be blocked 

upon entering the pelvic cavity from above is the round ligament 
with its n. spermaticus externus. This is accomplished by having 
the assistant gently lift the abdominal wall in that part of the 





THE UTERUS 


495 


incision above the round ligament (Fig. 216), allowing the operator 
to see some portion of the ligament which is carefully picked up 
with the long tissue forceps and steadied while the needle is inserted 
into it. A point well toward the front is chosen as the nerve supply 
comes from the direction of the abdominal wall. (An excellent 
procedure is to advance the needle subperitoneally along the anterior 
abdominal wall until its point reaches the parietal origin of the 
round ligament.) A wheal is raised and an effort made to extend 
the infiltration beneath the peritoneum on both sides of the round 
ligament. This maneuver is repeated on the opposite side and 
the subsequent technic will depend upon the operative procedure 
which is to be carried out. If the appendix is to be removed, this 
may be done while the solution which has been injected into the 
round and broad ligaments is given plenty of time in which to 
disseminate. A delay of a few minutes is desirable rather than 
otherwise. 


Anterior splanchnic anesthesia of the sacral plexus may be used 
as a preliminary to extensive pelvic work in cases in which the 
pelvic brim comes easily into view. During recent years we have 
used this method quite extensively, and when the retroperitoneal 
infiltration can be made directlv under the vision it is to be con- 

KJ 

sidered the method of choice. (See Chapter IV.) 


THE UTERUS. 




Like the adnexa, the uterus presents surgical conditions which 
are both simple and complicated, and the manner of dealing with 
them will depend, among other things, upon the kind of pathology 
present and the operative procedure which is to be undertaken. 

Hysteropexy.— Many of the various suspension operations may 
be performed with the anesthesia of the round ligaments (Fig. 216, 
page 494). If one wishes to pierce the broad ligament beneath 
the tubes, as in the Baldy-Webster operation, it is only necessary 
to infiltrate the area about the point of puncture. When the 
round ligaments are to be attached to the fundus, it may be desirable 
to produce a wheal at the point where they are to be attached. 
The raising of the uterus from its pelvic bed may be somewhat 
disagreeable. If the organ is adherent special precautions are 
necessary and considerable difficulty may be encountered. The 
introduction of a ligature beneath each of the round ligaments 
will facilitate the elevation of the uterus, and this may be further 
aided by the use of the tenaculum in the fundus, provided one 
intends to attach the round ligaments to the fundus. As the 
fundus is elevated adhesions may be divided with the scissors after 


496 LOCAL ANESTHESIA IN SURGERY OF THE PELVIS 


anesthetizing the sacral splanchnics. The introduction of a 
vaginal pack with the patient to the knee-chest position before 
the operation will be found to aid the deliverance of the fundus 
from its pelvic bed, especially in non-adherent cases. In all this 
work a knowledge of the pain sense of the region will enable 
the surgeon to anticipate the production of slight pain, which 
in some cases cannot be avoided, and in this manner an extra 
effort to be exceedingly gentle may be put forth at the proper 
time, while in addition the patient may be cautioned regarding 
the possibility of some disagreeable sensation. In this manner 
one may carry out many procedures which, if attempted in the 
manner that one is accustomed to use with general anesthesia, 
would inevitably result in failure. 

For the external or internal Alexander operation, the same technic 
as that used for oblique inguinal hernia is used, in addition to the 
blocking of the round ligaments when they are encountered. 

A great aid to the surgeon when making suspension operations 
under local anesthesia is the preliminary packing of the vaginal 
vault. One of the “high points” which one must pass comes when 
the retroverted uterus is lifted from its pelvic bed. Provided a 
splanchnic anesthesia has been produced manipulations of the 
uterus may be carried out without stint. However, for the ordinary 
simple pelvic work such as hysteropexy, anterior splanchnic anes¬ 
thesia should not be required. We have found that by placing the 
patient in the knee-chest position and packing the vagina with 
gauze the elevation of the uterus has been greatly facilitated after 
the abdomen had been opened. The packing may be introduced 
before the patient leaves the bed to go to the operating room. 

Myomectomy.— Tumors of large size can be handled under local 
anesthesia provided they lie in a favorable position and have 
generous pedicles. Large tumors which totally obstruct the view 
of the pelvis both before and after delivery of the tumor, so that 
the pedicle cannot be seen and blocked, may not be amenable to 
this form of anesthesia. Again, tumors with short pedicles or 
uterine fibroids involving the whole uterus may, on the one hand, 
so obstruct the view that they will present no chance for the block¬ 
ing of the nerves supplying this organ, and, on the other hand, the 
delivery of such a tumor may put the short pedicle on the stretch 
as the abdominal wall slips beneath it, so that the patient is caused 
too great discomfort. In cases of this kind the condition must 
be met as on page 493. As a rule, however, the round liga¬ 
ments can be seen before the delivery of the tumor and they 
should be generously blocked upon appearing (Fig. 216, page 494), 
The broad ligaments should also be infiltrated when brought into 
view, care being taken to avoid the veins, which is a comparatively 


THE UTERUS 


497 


simple matter, as the subperitoneal injection makes plainly visible 
the course and the amount of fluid as it flows in. 

Abdominal Hysterectomy. —The supravaginal amputation of the 
cer\ ix in uncomplicated cases is one of the most satisfactory oper¬ 
ations undei local anesthesia. It requires only a blocking of the 
lound and broad ligaments and a subperitoneal infiltration about 
the uterine cervix before the clamps are applied (Fig. 217). The 
legion of the uterine arteries is sensitive, especially where the 
blocking has not been perfectly done, and it is the author’s practice 


Fig. 217.—Abdominal hysterectomy. Anesthesia technic; anterior splanchnic 

anesthesia. X, round ligament block. 

to clamp down to the artery, divide the broad ligament to this 
point, and, before clamping the artery, inject a few drops of the 
novocain-adrenalin solution directly into the region of the proposed 
incision. Provided the exposure is perfect and the pelvis free of 
intestines, or nearly so, this operation can lie painlessly performed. 
The most common cause of discomfort will be due to an attempt 
on the part of the operator to raise the organ out of the pelvis during 
his manipulations. Traction must be avoided in order to perform 
the operation painlessly. Blocking of the ovarian and tubal 
32 












498 LOCAL ANESTHESIA IN SURGERY OF THE PELVIS 


pedicles should be made proximal or distal to these organs, depend¬ 
ing upon whether or not they are to remain with the patient. Case 
No. 13348 is an example of a patient who underwent this operation 
for uterine fibroid with complications. (See also Case No. 13587, 
page 501.) 

Report of Case No. 13348. 

Mrs. S. T. W., aged forty-eight years, entered hospital January 
10, 1920. 

Diagnosis: Uterine fibroids (multiple); double hydrosalpinx; 
pelvic adhesions. 

Operation: Abdominal subtotal hysterectomy; salpingectomy; 
division of adhesions. 

Preliminary Medication: The patient Was given pantopon gr. 
J and scopolamin gr. ytto two hours before operation and the 
dose repeated one hour before operation. 

Anesthesia: Sacral, 90 cc 0.5 of 1 per cent novocain-adrenalin 
solution, and infiltration of abdominal wall, 100 cc. 

Operation: Midline incision from umbilicus to the pubes. The 
omentum was adherent to the parietal peritoneum. The adhesions 
were divided along the “white line.’’ The sigmoid and omentum 
were adherent to a large fibroid tumor, and were separated in the 
same Way. The tumor was then lifted out of the abdomen by means 
of a myoma screw without pain to the patient. Hysterosalpin- 
gectomy was performed between clamps. The operation was 
completed without the patient’s pulse going above 80. In this 
case no anesthesia was used in the peritoneal cavity. The pre¬ 
liminary sacral anesthesia seemed to be sufficient. 

Panhysterectomy.— In blocking for this operation the same 
technic is to be employed as for the operation of subtotal hyster¬ 
ectomy (Figs. 214, 215 and 216, pages 492-494), except that 
the tissues between the bladder and cervix in front and the 
rectum and cervix behind must be thoroughly infiltrated. This 
is not a difficult procedure and is not to be considered dangerous, 
if the ordinary precautions are followed. The needle should be 
made to follow the uterine wall closely and should be kept moving 
while the injection is being made. (Fig. 217, page 497.) The influx 
of the solution at once forces the bladder or rectum, as the case 
may be, far away from the cervix and out of harm’s way. Before 
clamping the uterine vessels the needle should be carried down 
laterally to the cervix and a liberal amount of the solution deposited 
on both sides of the uterus. The edema produced, instead of being 
a hindrance is really an aid in making the dissection, as the bladder 
and rectum are carried farther away from the field of operation 
than would otherwise be the case. One has but to hug the wall 



THE UTERUS 


499 


of the uterus and vagina to be entirely safe. By the time the 
vessels are ligated and one is ready to apply the sutures the edema 
will have largely disappeared. Case No. 15448 is one in which 
panhysterectomy was performed upon an individual who had 



Report of Case No. 15448. 

Mrs. A. O. I., aged fifty years, entered hospital January 30, 1922. 

Diagnosis: Uterine fibroid with secondary anemia. 

Operation: Panhysterectomy. 

Anesthesia: Local infiltration with anterior splanchnic. 

History: Patient’s hemoglobin was 26 per cent on entering the 
hospital and it was increased 31 per cent by means of iron hypo¬ 
dermically as well as transfusions. 

Operation: Two weeks after entering the hospital a panhyster¬ 
ectomy was performed, using direct infiltration of the abdominal 
wall combined with anterior splanchnic anesthesia. The abdomen 
was opened with negative pressure, one gauze pack inserted to 
prevent soiling and the round and broad ligaments were infiltrated 
as shown in Fig. 216, page 494. The uterus was then delivered and 
was the size of a baby’s head, soft, and was considered to be 
possibly sarcoma. Panhysterectomy was therefore performed 
between clamps. Drainage was instituted with the aid of a 
preliminary pack in the vaginal vault as described on page 
507. Although the pulse and blood-pressure remained unchanged 
the hemoglobin dropped 6 per cent during the operation. This 
patient made an uneventful recovery, took nourishment directly 
after the operation in considerable quantities and showed almost 
no reaction to the operative procedure, notwithstanding the fact 
that she was an extremely poor risk. 

Case No. 13587 (page 501), a profoundly septic case requiring 
hysterectomy, double salpingectomy and left oophorectomy was 
also handled by abdominal infiltration and anterior splanchnic 
anesthesia. 

Equally good results may be obtained by the preliminary intro¬ 
duction of 90 cc of 1 per cent novocain-adrenalin solution into the 
sacral canal (Fig. 28, page 117). Even better anesthesia may be 
secured by the establishment of trans-sacral anesthesia. Infiltration 
through the vaginal vault as a preliminary gives one most excellent 
anesthesia. (See Fig. 147, page 353.) 

Report of Case No. 9705. 

Mrs. N. D., aged forty-four years, entered hospital March 
5, 1916. 


500 LOCAL ANESTHESIA IN SURGERY OF TIIE PELVIS 


Diagnosis: Chronic endometritis; bilateral salpingitis; right 
ovarian abscess; recurrent appendicitis; laceration of perineum. 

Operation: March 24, 1916. Abdominal hysterectomy. (Sub¬ 
total); double salpingectomy; right oophorectomy; appendectomy; 
perineorrhaphy. 

Anesthesia: Local infiltration; pelvic splanchnic. 

Bilateral blocking of the ilioinguinal and iliohypogastric nerves 
was done as well as subdermal blocking on line of proposed incision, 
using 120 cc of 0.5 per cent novocain-adrenalin solution. A typical 
Pfannenstiel incision and flap were made and the abdomen opened 
with negative pressure. Several adherent loops of intestine were 
separated from the uterus and tubes by sharp dissection. The 
small intestine was held above the pelvic brim by means of a gauze 
pack which was introduced without complaint. The round and 
broad ligaments and the right ovarian pedicle were infiltrated. 
The uterus, bilateral pus tubes and the right ovary which con¬ 
tained a cyst were removed. The anesthesia was reinforced when 
the region of uterine arteries was reached. The appendix was 
adherent to the lateral abdominal wall, the patient having had 
three attacks of appendicitis. Omental adhesions in this region 
were divided, the appendix removed, after which the peritoneal 
toilet was completed and the wound closed. The operation on 
the perineum followed, using infiltration block with 0.5 of 1 per 
cent novocain-adrenalin. The perineum was repaired with chro- 
micized gut. 

The record shows that this patient did not complain of pain 
except when sponging in the cul-de-sac was done. Pulse at close 
of operation was 88. Recovery was uneventful. 


FALLOPIAN TUBES. 

All work upon the non-adherent tubes may be done painlessly 
after the blocking of the round ligament and the mesosalpinx. 
Densely adherent tubes and tubo-ovarian abscesses come in the 
same class with the adherent uterus and malignant disease and 
will be considered later under a special technic which is to be 
recommended in this variety of pelvic work. However, it is sur¬ 
prising how much may be done under a perfect exposure with the 
pelvis free of intestines, by working entirely in the open, gently 
lifting the different organs with long tissue forceps and clipping 
the adherent bands as they appear. In this manner adherent 
masses which resist finger enucleation and require the use of great 
force may be cut loose with a scalpel or scissors and removed with 
comparative ease. Pelvic work should be done only under direct 


FALLOPIAN TUBES 


501 


vision. Cases No. 13587 and 10142 are examples of tubal 
pathology which was removed under local infiltration and pelvic 
splanchnic block. 

Report of Case No. 13587. 

Mrs. J. E., aged thirty-nine years, entered hospital November 
25, 1921. 

Diagnosis: Double pyosalpinx; pelvic peritonitis; right ovarian 
cyst; recurring appendicitis; and left ovarian abscess. 

Operation: Subtotal hysterectomy; double salpingo-oophorectomy; 
appendectomy. 

Anesthesia: Local infiltration; anterior splanchnic (pelvic). 

History: This patient had had pelvic drainage of the posterior 
vaginal fornix established three weeks previously. 

Anesthesia: 90 cc of a 1 per cent novocain-adrenalin solution were 
used in infiltrating. 

The abdomen was opened by a midline incision 15 cm. in length. 
The pelvis was found free of small intestine, excepting two loops, 
which were attached to the fundus and one of the tubes respectively. 
Separation of these adhesions was accomplished without pain 
to the patient. At the pelvic brim a subperitoneal infiltration 
with novocain-adrenalin solution was made. Following this both 
round and broad ligaments were blocked, after gently elevating 
the abdominal wall at the lower end of the incision. Salt pads 
were then introduced for the purpose of protecting the general 
peritoneal cavity from becoming infected. These pads and the 
intestines above them were held out of the field bv the use of wire- 
spring retractors. With long delicate tissue forceps the distended 
tubes were elevated and cut free from their pelvic attachments 
with scissors. A right ovarian cyst and a left ovarian abscess, 
both adherent in the pelvis, were freed in the same manner. The 
broad ligaments were then clamped and the anesthesia was rein¬ 
forced after cutting between the first pair of clamps on either side, 
in this manner carrying the solution directly to the region of the 
uterine arteries. Subtotal hysterectomy was then completed and 
drainage instituted with the aid of a preliminary pack of gauze 
in the vaginal vault as described on page 507. Anesthesia in this 
case was perfect. 

Note .—The use of a preliminary sacral block would perhaps 
have rendered the work less difficult. Especially would this be 
true in a case in which, for any reason, a less excellent exposure 
had been obtained. Had we, upon opening the abdomen of this 
patient, been confronted with a pelvis completely filled with coils 
of small intestine, it might have been impossible to exclude these 
from the field of operation, at least without delivering them upon 


502 LOCAL ANESTHESIA IN SURGERY OF THE PELVIS 


the abdominal wall, which procedure should be avoided il possible. 
In a number of cases of this kind the author has been compelled 
to resort to mixed anesthesia in order to complete the operation 
without pain. 


Case Report No. 10142. 

Mrs. A. C. M., aged twenty-nine years, entered hospital October 
15, 1917. 

Diagnosis: Unruptured ectopic pregnancy. 

Operation: Right salpingectomy. 

Anesthesia: Right midline infiltration, using 150 cc of a 0.5 per 
cent novocain-adrenalin solution. 

The abdomen was opened with the patient in Trendelenburg 
position and the pelvis found free of small intestines. The right 
tube presented a tumor the size of a lemon. A small amount of 
blood was found in the pelvis. A right salpingectomy was per¬ 
formed after an infiltration of the mesosalpinx. No gauze was 
used in the abdominal cavity. There was no expulsive effort and 
the anesthesia was ideal in every way. 


CESAREAN SECTION. 

Abdominal Cesarean section on account of the factors which 
furnish its indications often demands the safety offered by the 
use of local anesthesia. The classical operation may be performed 
under a simple infiltration of the abdominal wall (see Case Report 
No. 10796). In these cases it is better to avoid the delivery of 
the uterus, which is indeed generally unnecessary. The abdomen 
should be opened with a negative pressure and no sponges should 
be necessary, as a rule, for the retention of the intraperitoneal 
viscera. The uterine wall is not sensitive and requires no infil¬ 
tration. Should hysterectomy be necessary an anterior splanchnic 
infiltration of the broad and round ligaments may be carried out 
after the abdomen is opened. 

With the more complicated operations, as, for instance, the 
extraperitoneal operation, a transverse infiltration block extending 
from the umbilicus to the anterior-superior spine on either side, 
will answer the purpose. In these cases, operation will be facilitated 
by an infiltration of the subperitoneal tissue as soon as exposed. 

Vaginal ('esarean section may be accomplished by the perineal 
and cervical circumferential block described in Chapter XI, pages 
351 and 353. The following case illustrates the application of 
abdominal section: 


THE OVARY 


503 


Report of Case No. 10796. 

Mrs. I). F., aged twenty-three years, entered hospital March 
2, 1917. 

Diagnosis: Pregnancy; contracted pelvis. 

Operation: Abdominal Cesarean section. 

History: This patient had given birth to two children by abdo¬ 
minal C esarean route, ether anesthesia being employed in both 
instances. 

Anesthesia: Local infiltration using 120 cc of 0.5 per cent novocain- 
adrenalin. 

Operation: At term. Midline infiltration 1 cm. to the left of 
the umbilicus. Negative intra-abdominal pressure obtained. The 
uterus was at once incised, without using intraperitoneal anesthesia. 
The incision proved to be over the placental site and the placenta 
w r as pushed aside. An arm presented, it was returned to the 
uterus, a leg grasped and the child was delivered. This procedure 
caused the patient no pain. Pituitrin was given hypodermically 
at this stage and the uterus contracted into a rigid mass. The 
patient complained of a typical long labor pain throughout the 
time the placenta was being delivered. Uterus and abdominal 
incision were then closed, no gauze having been used in the peri¬ 
toneal cavity. 

Note .—In this case the child was introduced to its mother 
thirteen minutes after beginning of induction of anesthesia. No 
gauze and no instruments — not even the gloved hand—came 
in contact with any of the intra-abdominal viscera. There was no 
postoperative nausea, vomiting, thirst or distention. The child 
weighed 8 pounds 14 ounces. Both mother and child left the 
hospital in good condition fourteen days later. 

THE OVARY. 

In operating upon the ovary under local anesthesia exposure 
will greatly facilitate the success of any procedure. The normal 
ovary is not particularly sensitive and may be handled to a certain 
extent without pain to the patient. However, it should not be 
subjected to severe pressure and traction must be avoided. As a 
rule the ovarian pedicle is blocked (Fig. 218) and the organ is steadied 
while the needle is being introduced through the peritoneal coat. 
The greatest difficulty is encountered in cases of ovarian cysts or 
adherent infected ovaries. Large cysts are best evacuated before 
delivery is attempted. For the purpose of avoiding the possibility 
of the dissemination of malignant particles the evacuation should 
be made by suction. (See Fig. 219.) 


504 LOCAL ANESTHESIA IN SURGERY OF THE PELVIS 



Fig. 218.—Ovarian cyst. Anesthesia technic. Anterior pelvic splanchnic 

anesthesia. Blocking ovarian pedicle. 



Fig. 219.—Ovarian cyst (malignant). Photograph of Case No. 11936 
during operation. Evacuation of cyst by suction. 











THE OVARY 


505 


Once the cyst is reduced in size so that delivery may he easily 
made and the ovarian pedicle exposed blocking may he accomplished 
before the removal of the cyst. Traction should be most carefully 
avoided at this juncture. Adherent ovarian cysts offer more 
difficulty. However, adhesions between the cyst wall and the 
parietal peritoneum may be divided as they are met by the method 
described in tig. 170, page 396. Separation of the other abdominal 
viscera from the cyst wall is not painful provided strong traction 
is avoided. 

the case below is one of cyst formation with adenocarcinoma 
and shows how suction was utilized to evacuate the cyst in pre¬ 
paring for removal: 


Record of Case No. 11936. 


Mrs. W. F. A., aged forty-four years, entered the hospital January 
31, 1919. 

Diagnosis: Ovarian cyst with papillary adenocarcinoma. 

Operation: Hysterectomy; bilateral salpingectomy; right oopho¬ 
rectomy ; appendectomy. 

Anesthesia: Local infiltration; pelvic splanchnic. 

History: The patient has had frequent “catching” pains in lower 
right abdomen for past four years. , The duration of pains was 
short and often accompanied by distention of abdomen, nausea 
and soreness so that the corset was not tolerated. The last attack 
began a month ago and has not subsided. Her appetite has been 
poor and bowels sluggish since onset of illness and the patient thinks 
she has been jaundiced. There have been no urinary symptoms. 
Menstrual history was negative and she has never been pregnant. 

Examination showed a large fluctuating tumor occupying the 
abdominal cavity from the symphysis pubis to the costal margins 
with bulging in the flanks. 

Anesthesia and Operative Technic.—A midline infiltration was 
made using 150 cc novocain-adrenalin solution and the abdomen 
was opened with a 10 cm. incision. The cyst which presented 
was punctured with a large trocar. By means of suction as shown 
in Fig. 219, 6000 cc of brown opaque thick fluid were aspirated 
so that the partially collapsed tumor could be drawn through the 
wound. It was found to take origin in the right ovary, which was 
removed along with both tubes and the uterus, as the malignant 
character of the cyst was noted on gross examination. Appendi- 
cectomy was also performed. All raw surfaces were peritonized 
and the wound was closed without drainage. 


50G LOCAL ANESTHESIA IN SURGERY OF THE PELVIS 


Note .—This patient had an uneventful postoperative convales¬ 
cence, but by pneumoperitoneum two and a half years later, on 
May 30, 1922, a shadow shows across the pelvis in the region of 
amputated broad ligaments with the patient in Peterson’s modified 
knee-chest position. However, the cervix is freely movable and 
no mass can be felt. 

Intraligamentous cysts maybe evacuated following a subperitoneal 
infiltration and an anterior splanchnic anesthesia proximal to the 
growth. Infected cases offer the greatest difficulty, and while we 
have been able to accomplish complete ablation in a large percentage 
of infected pelvic cases of tubo-ovarian abscesses, the execution 
of such a procedure offers considerable difficulty. The abdomen 
must be opened with a perfect negative pressure. The pelvis 
must be free of small intestine. In other words, the exposure must 
be perfect. These cases, infected as they are, offer to the operator 
a peritoneal cavity which is more or less on the qui vive. There¬ 
fore it requires every artifice and all of the strategy at one’s command 
to overcome the obstacles presented. A preliminary sacral, trans- 
sacral or parasacral anesthesia will, in most instances, act as an 
excellent adjunct. However, with a perfect exposure and the 
protection of an anterior splanchnic anesthesia preferably at the 
pelvic brim, combined with the proper surgical strategy, it is sur¬ 
prising to what extent one may carry through surgical procedures 
in badly infected pelvic cases. 

Case No. 13587 (page 501) is an example of a case in which the 
whole pelvis presented a mass of infected adherent organs, and 
yet a hystero-salpingo-oopliorectomy was carried out under an 
excellent anesthesia. 

Next to exposure the delicate handling of tissues is most essential. 
Key bands should be cut rather than torn and they may be 
exposed by gently lifting the adherent organ by means of long, 
delicate tissue forceps. What has been said regarding the Fallopian 
tubes applies with equal force in the case of the ovaries. They 
will be found to be held in place by a few anchoring bands and will 
be most easily mobilized by the cutting of these bands. It is sur¬ 
prising to note the comparative ease with which this plan may be 
applied in cases which were formerly subjected to great force in 
making the blind infiltration of abdominal pelvic organs. Case 
No. 11494, which follows, illustrates the manner in which a large 
cyst of the ovary accompanied by a dermoid cyst and uterine 
fibroids was treated surgically with local infiltration and pelvic 
splanchnic anesthesia: 


POSTOPERATIVE DRAINAGE 


507 


Report of Case No. 11494. 

Miss M. I)., aged twenty-nine years, entered hospital April 
26, 1918. 

Diagnosis: 1 terine fibroids; dermoid cyst of left ovary; simple 
cyst of right ovary, established by means of pneumoperitoneum 
and roentgen rays. 

Operation: Subtotal hysterectomy; enucleation of dermoid cyst; 
excision of ovarian cyst; appendectomy. 

Anesthesia: Local infiltration; pelvic splanchnic. 

Midline infiltration below the umbilicus was made. The abdomen 
was opened with negative pressure. Some of the oxygen from the 
pneumoperitoneum of twenty-four hours before still remained. 
The abolition of the muscular reflexes, the presence of free oxygen 
gas in the abdominal cavity and the Trendelenburg position left 
the lower half of the abdomen entirely free of small intestine. The 
wall of the cyst of the right ovary was punctured and the cyst 
emptied by suction. (Fig. 219.) Vertical retraction of the abdominal 
wall at the lower end of the incision brought the round and broad 
ligaments into view, and they were infiltrated with a solution of 
novocain-adrenalin 0.7 of 1 per cent. A dermoid cyst of the left 
ovary, the size of a baseball, was shelled out without leakage. The 
uterine fundus contained numerous interstitial and subserousfibroids. 
Subtotal hysterectomy and appendectomy were done. Throughout 
the operation no gauze pads were placed in the abdominal cavity. 
Following the operation this patient received J gr. morphine hypo¬ 
dermically during the first night, and, according to the record, she 
slept well. There was no nausea or vomiting, and she took fluids 
in moderate amounts during and immediately after operation. 
An accurate diagnosis was made in this case by means of roentgen 
rays after pneumoperitoneum. 


POSTOPERATIVE DRAINAGE. 

Where drainage is to be employed in doing pelvic work it has 
been the author’s habit, when this could be anticipated, to care¬ 
fully pack the vaginal vault with sterile gauze just previous to 
operation. When establishing drainage during the abdominal 
operation a non-absorbing suture is passed through the meshes of 
this gauze as soon as it is exposed to view from above and the 
abdominal drain is attached to it. Thus the abdominal drain can 
be drawn into the vagina as the vaginal gauze (which is attached 
to a long tape and allowed to hang from the foot of the table) is 
withdrawn. 


508 LOCAL ANESTHESIA IN SURGERY OF THE PELVIS 


The introduction of drains into the vagina from above is fre¬ 
quently the cause of discomfort to the patient and embarrassment 
to the surgeon. I have found the above-mentioned maneuver a 
great help here because, as not infrequently happens, some simple 
detail may interfere more with the performance of an operation 
under local anesthesia than will the major portions of the procedure. 

The making of a circumferential infiltration about the uterine 
cervix may precede the abdominal packing, and therefore the two 
adjuncts may be carried out as a preliminary to the abdominal 
operation without a great deal of trouble. 


INDEX. 


A 

Abdomen, gunshot wounds of, local 
infiltration in, 386 
novocain-adrenalin in, 
386 

opening of, anticipated pathology 
in, 390 

in appendicitis, 478 
conservation of blood supply 
in, 389 

of nerve supply in, 389 
facility with which incision 
may be made and closed, 
390 

importance of division of 
muscular as compared with 
aponeurotic tissue, 388 
surgery of, local anesthesia in, 379, 
419 

closure of wound 
and, 394 

direction, site and 
choice of incision 
and, 385 

duties of psycho¬ 
anesthetist and, 
398 

general considera¬ 
tions of, 373 

making the incision 
and, 397 

muscular relaxation 
and, 398 

position of patient 
in, 384, 419 

relaxation afforded 
during and after 
operation and, 391 
resultant scar in, 387 
trans-rectus incision in upper 
abdomen, 387 

Abdominal cavity, opening of, in 
surgery of gall-bladder, 441 
exploration, local anesthesia in, 399 
hysterectomy, novocain-adrenalin 
in, 498 

pantopon in, 498 
sacral anesthesia in, 498 
scopolamin in, 498 


Abdominal incision in exposure of 
pelvis, 490 

infiltration in appendicectomy, 481 
organs, examination of, local anes¬ 
thesia in, 400 

rectopexy, local anesthesia in, 375, 
376 

viscera, handling of, 129 
wall, nerve supply of, 379 

opening of, in introduction of 
anesthetic solution, 153 
surgery of, local anesthesia in, 
402 

Abortion, incomplete, local anesthesia 
in, 353 

infiltration in, 353 
novocain-adrenalin in, 353 
Abscess, intra-abdominal, drainage of, 
technic of, 486 

of liver, local anesthesia in, 438 
of lungs, general anesthesia and, 22 
pelvic, local anesthesia in, 360 
infiltration in, 360 
sacral anesthesia in, 361 
pulmonary, local anesthesia in, 266 
infiltration in, 267 
paravertebral block in, 267 
Absence of vagina, congenital, local 
anesthesia in, 358 

Accessory obturator nerve, anatomy of, 

177 

Acetonuria, general anesthesia and, 18 
Acidosis, general anesthesia and, 19 
Adenitis, bilateral cervical, novocain- 
adrenalin in, 234 
suppurative cervical, novocain- 
adrenalin in, 233 
tuberculous cervical, novocain- 
adrenalin in, 235 
Adenoma of breast, cystic, 254 

local anesthesia in, 254 
intrathoracic toxic thyroid, cervi¬ 
cal block in, 243 
local infiltration in, 
243 

saligenin in, 243 

Air dilatation in cystotomy, 329 
Albuminuria, chloroform anesthesia 
and, 28 

Alocain-S as local anesthetic, 39 





510 


INDEX 


Alveolar nerves, anatomy of, 168, 169 
process of inferior maxilla, carci¬ 
noma of, 217 
excision of glands of 
neck in, 217 
resection of inferior 
maxilla in, 217 

Alypin as local anesthetic, 38 
Amputation of arm, brachial block in, 
287 

local anesthesia in, 287 
novocain-adrenalin in, 287 
of leg, local anesthesia in, 287 
novocain-adrenalin in, 288 
transverse infiltration block 
in, 287, 288 

of penis, local anesthesia in, 341 
of toe, local anesthesia in, 314 
Amputations, local anesthesia in, tech¬ 
nic of, 286 

of lower extremity, 287 
of upper extremity, 286 
Anatomy of sensory nervous system, 
166 

Anemias, ether anesthesia and, 25 
Anesthesia, anterior splanchnic, in 
cholecystectomy, 452 
in choledochotomy, 454 
in duodenal ulcer, 425, 
426 

in gastric ulcer, 424, 425 
in surgery of gall-bladder, 
443 

arterial, 111, 114 
technic of, 114 
brachial, technic of, 129 
circumferential infiltration of 
Hackenbruck, 112 
conduction, 111 
general, 17 

acetonuria and, 18 
acidosis and, 19 
chloroform, 26 

albuminuria and, 28 
arrhythmia and, 27 
cardiac disorders and, 27 
circulatory disorders and, 
27 

system and, 26 
cirrhosis of liver and, 28 
dyspnea and, 27 
enlarged bronchial glands 
and, 27 

thymus and, 27 
fatty degeneration of 
liver and, 26 
hepatic disorders and, 28 
renal disorders and, 28 
respiratory disorders and, 
27 

yellow atrophy of liver 
and, 28 


Anesthesia, general, dangers of, 29 

effects of, on general system, 

18 

on special organs and 
tissues, 21 
ethanesal, 25 
ether, 24 

anemias and, 25 
blood and, 24 
cardiovascular disease 
and, 25 

diabetes mellitus and, 25 
heart and, 24 
kidneys and, 24 
nephritis and, 25 
nervous system and, 24 
respiratory disorders and, 
25 

gangrenous pneumonia and, 
22 

ill effects of, 18 
lung abscess and, 22 
mortality of, 31 
nitrous oxide, 28 
postoperative shock and, 20 
respiration and, 19 
toxicity of, 18 
infiltration, 111 

advantages of, 139 
block, 112 

direct and regional compared, 
137 

technic of, 144 
intraneural, 111 
intraspinal, 111 
local, 33 

acidosis research upon patient 
after using, 48 

advantages of, after opera¬ 
tion, 63 

before operation, 63 
cooperation of patient, 
61 

during operation, 61 
“silent field,” 61 
armamentarium for, 82 
attitude of patient in relation 
to, and upon what it de¬ 
pends, 64 

automatic lifter in, 101 

description of, 103 
wire-spring retractor in, 
97 

causes of failure of, in abdom¬ 
inal surgery, 147 
choice of methods of admin¬ 
istering, 143 

definition of terms emploved, 

111 

discussion of, with patient, 68 
equipment for, 82 

necessity for special, 82 


INDEX 


511 


Anesthesia, local, Farr’s pneumatic in¬ 
jector in, 88 
detailed description 
of, 92 

operative mechanism 
of, 93 

gauze retractor and, 156 
general considerations regard¬ 
ing induction of, after 
the time has arrived 
for giving anesthetic, 
148 

intelligence of patient 
and, 66 

practitioner in relation 
to, 75 

technic of, 111 
goiter clamp in, 104 
heavy bone shears in, 108 
hypodermoclysis and, 162 
intestinal forceps in, 110 
introduction of solution in, 149 
medical teaching in relation 
to, 74 

methods of producing, 33 
allocain-S, 39 
alypin, 38 
apothesin, 38 
benzyl alcohol, 41 
benzylcarbinol, 42 
beta-eucain, 35 
butyn, 43 
cocain, 35 
cold, 33 
epinephrin, 44 
nirvanin, 39 
novocain (procain), 
45 

phenol, 34 
pressure, 34 
quinin and urea 
hydrochloride, 40 
saligenin (salicain), 
42 

stovain, 37 
tropacocain, 36 
music and, 162 
needles for infiltration, 86 
operating room deportment 
and, 159 
lighting in, 95 
table for, 83 

arm rests, 83 
tilting of, 84 

preparation of patient for 
operation under, 135 
principles of application of, 
to surgery, 111 
progress of, and upon what 
it depends, 78 
prostatic “hook” in, 108 
retractor in, 105 


Anesthesia, local, psychic aspects, at¬ 
tention to, by as¬ 
sistants and, 69 
of surgical case and, 
66 

“shock” and, 70 
psycho-anesthetist and, 160 
rectal dilators in, 109 
reduction of trauma and, 62 
relative desirable properties 
of, 52 

sponging and, 154 
surgical strategy and, 161 

technic and some ad¬ 
juncts demanded by, 
154 

syringes for, 85 
technic of, desirability of 
simplifying, 139 
tying of ligatures and, 154 

Farr’s three-forceps 
and four-forceps 
tie, 156 

Grant’s method, 156 
viscera retainer in, 106 
mixed, 78 
narco-local, 72 

technic of, 132 
parasacral, technic of, 119 
paravertebral, technic of, 122 
patient’s interests in, 55 
perineural, 111 
problem of, 55 

hospital in relation to, 74 
psycho-local, 79 
regional, 111 

application of, 136 
of sacral nerves, 117 
technic of, 185 
splanchnic, technic of, 124 
anterior, 125 

Farr’s method of, 127 
posterior, 124 
synergistic, technic of, 133 
trans-sacral, technic of, 121 
venous, 111, 112 
technic of, 112 
Anesthetic, choice of, 55 

after-pains and, 60 
apprehension and, 58 
comfort and, 58 
convalescence and, 60 
discomfort and, 58 
efficiency and, 56 
postoperative discomfort and, 
60 

safety and, 56 
suffering and, 59 

solution, introduction of, technic 
of, 149 

anesthetization of 
skin line, 149 


512 


INDEX 


Anesthetic solution, introduction of, 

technic of, deep 
layer infiltration, 
15 i 

initial wheal, 149 
negative intra-abdo¬ 
minal pressure, 153 
opening of abdomi¬ 
nal wall, 153 
skin incision, 153 

Anesthetist, nurse versus physician, 76 
surgeon his own, 77 
Ankle-joint, nerve supply of, 310 

surgery of, local anesthesia in, 310 
Ankylosis of elbow-joint, brachial 
block in, 295 
local anesthesia in, 294 
infiltration in, 295 
saligenin in, 295 
of hip, local anesthesia in, 302 
Anococcygeal nerves, anatomy of, 182 
Anterior colporrhaphy, local anesthesia 
in, technic of, 354 
crural nerve, anatomy of, 177 
splanchnic anesthesia in panhys¬ 
terectomy, 499 
in pelvic operations, 494 
in pyosalpinx, 501 
thoracic nerve, anatomy of, 172 
tibial nerve, anatomy of, 181 
Anus, fissures of, circumferential infil¬ 
tration in, 369 
sacral anesthesia in, 369 
nerve supply of, 363 
surgery of, circumferential infil¬ 
tration in, 363 
local anesthesia in, 362 

choice of methods of, 
362 

position of patient 
in, 362 

postoperative comfort in, 377 
Apothesin as local anesthetic, 38 
Appendiceal abscess, drainage of, tech¬ 
nic of, 486 

Appendicectomy, abdominal infiltra¬ 
tion in, 481 

delivery of acute appendix, tech¬ 
nic of, 482 

local anesthesia in, 447, 449, 450, 
452, 479, 484, 485 
infiltration in, 480, 485 
muscular relaxation in, 481 
novocain-adrenalin in, 485 
under varying conditions, 480 
Appendicitis, acute, 471 

local anesthesia in, 484, 485 
chronic, incisions in, 472 
Elliott’s, 475 
McArthur’s gridiron, 472 
transverse abdominal, 
473 


Appendicitis, deep infiltration in, tech¬ 
nic of, 476 

delivery of appendix in, technic of, 
479 

local anesthesia in, 450, 452 
management of, medical, 471 
operative, 421 
preoperative, 471 
surgical, 471 

meso-appendix infiltration in, tech¬ 
nic of, 478 

opening of abdomen in, 478 

negative intra-abdominal 
pressure, 478 

position on operating table for, 472 
postoperative course of, effect of 
anesthesia on, 472 
subacute, 471 

local anesthesia in, 479 
subdorsal infiltration, technic of, 
476 

Appendix, pelvis and, local anesthesia 
and, 487 

position on operating table 
and, 488 

surgery of, local anesthesia in, 471 
Arm, amputation of, brachial block in, 
287 

local anesthesia in, 287 
novocain-adrenalin in, 287 
hemangioma of, local anesthesia 
in, 272 

transverse infiltration block of, 274 
Armamentarium for local anesthesia, 82 
Arnold, nerve of, anatomy of, 170 
Arrhythmia, chloroform anesthesia 
and, 27 

Arterial anesthesia, 111, 114 
technic of, 114 

Arthritis of hip, local anesthesia in, 289 
suppurative, local anesthesia in, 
technic for drainage in, 289 
Anthroplasty of elbow-joint, local 
anesthesia in, 295 
of hip, local anesthesia in, 302 
infiltration, 302 
nitrous oxide and oxygen in, 
302 

Arthrotomy, local anesthesia in, 289 
Artificial vagina, local anesthesia in, 358 
Aspiration of cysts, local anesthesia in, 
457 

Atheromata of seal}), 190 
Atresia of hymen, infiltration block in, 
358 

local anesthesia in, 357 
Atrophy of liver, chloroform anesthesia 
and, 28 

Auricular nerves, anatomy of, 170 
Auriculotemporal nerve, anatomy of, 
169 

Automatic lifter, 101 


INDEX 


513 


Automatic lifter, description of, 103 
wire-spring retractors, 97 


B 

Base of skull, fracture of infiltration 
block in, 219 

Bell, external respiratory nerve of, 
anatomy of, 172 

Benzyl alcohol as local anesthetic, 41 
Benzylcarbinol as local anesthetic, 42 
Beta-eucain as local anesthetic, 35 
Bilateral cervical adenitis, novocain- 
adrenalin in, 234 

Bile ducts, surgery of, local anesthesia 
in, 453 

Bladder, method of opening in supra¬ 
pubic cystotomy, 329 
surgery of, local anesthesia, 328 
Blood, ether anesthesia and, 24 
Bone, intramedullary autotransplant 
of, brachial block in, 284 
shears, heavy, 108 
transplantation of, local anesthesia 
in, technic of, 283 
from tibia, brachial block in, 
283 

circumferential block in, 
283 

local infiltration on leg in, 
283 

Bowel, distended, temporary drainage 
of, author’s rubber towel method, 
469 

Brachial anesthesia in excision of 
breast, 259 
technic of, 129 

block in amputation of arm, 
287 

in ankylosis of elbow-joint, 
295 

in carcinoma of breast, 260 
in fracture of radius, 278 
in fracture-dislocation of hum¬ 
erus, 293 

of shoulder-joint, 277 
in intramedullary autotrans¬ 
plant of bone, 284 
in oblique fracture of hume¬ 
rus, 293 

in subluxation of shoulder- 
joint, 293 

in transplantation from tibia, 
283 

Brain, decompression of, 191 

operations on, infiltration block 
in, 193 

local anesthesia in, 191 
novocain-adrenalin in, 193 
tumor of, 191 

excision of, 192 

33 


Breast, carcinoma of, brachial block in, 
260 

circumferential infiltration in, 
261 

intercostal block in, 261 
local anesthesia in, 260, 261 
infiltration in, 260 
midline infiltration in, 261 
novocain-adrenalin in, 260 
cystic adenoma of, 254 

local anesthesia in, 254 
excision of, 254 

anesthesia in, technic of, 257 
brachial anesthesia in, 259 
cervical block in, 259 
local anesthesia in, 260, 261 
radical, 256 

subdermal infiltration in, 259 
surgery of, local anesthesia in, 251 
tumors of, benign, anesthesia in, 
technic of, 251 
infiltration block in, 252 
subdermal infiltration in, 
252 

malignant, 254 

Bronchial glands, enlarged, chloroform 
anesthesia and, 27 
Buccal nerve, anatomy of, 169 
Buccinator nerve, anatomy of, 169 
Bunions. See Hallux valgus. 

Butyn as local anesthetic, 43 


C 

Cadivilla pin, 311 

Calculi of ureter, local anesthesia in,323 
Calculus, vesical, novocain-adrenalin in, 
330 

suprapubic infiltration in, 330 
Cancer of pylorus, local anesthesia in, 
420 

Carbuncle of neck, infiltration block in, 
239 

local anesthesia in, 236 
Carcinoma of alveolar process of 

inferior maxilla, 
217 

excision of glands of 
neck in, 217 
resection of inferior 
maxilla in, 217 

of breast, brachial block in, 260 
circumferential infiltration in, 
261 

intercostal block in, 261 
local anesthesia in, 261 
infiltration in, 260 
midline infiltration in, 261 
novocain-adrenalin in, 260 
of inferior maxilla, transoral man¬ 
dibular block in, 219 



514 


INDEX 


Carcinoma of intestines, resection for, 
local anesthesia in, 460 
of larynx, infiltration block in, 249 
local anesthesia in, 249 
novocain-adrenalin in, 249 
pantopon in, 249 
scopolamin in, 249 
of lip, block dissection for, 236 
local infiltration in, 236 
of rectosigmoid, circumferential 
infiltration in, 463 
local anesthesia in, 462 
infiltration in, 462 
novocain-adrenalin in, 462 
sacral anesthesia in, 463 
of rectum, parasacral anesthesia 
in, 373 

sacral anesthesia in, 373 
trans-sacral anesthesia in, 373 
of stomach, local anesthesia in, 429 
resection for, anterior splanch¬ 
nic anesthesia in, 
429 

intercostal block in, 
429 

local infiltration in, 429 
novocain-adrenalin in,429 
Cardiac disorders, chloroform anes¬ 
thesia and, 27 

Cardiovascular disease, ether anes¬ 
thesia and, 25 

Cartilages, floating, infiltration block 
in, 308 

local anesthesia in, 308 
novocain-adrenalin in, 308 
Celiac plexus, anatomy of, 182 
Cervical adenitis, bilateral, novocain- 
adrenalin in, 234 
suppurative, novocain-adren¬ 
alin in, 233 

tuberculous, novocain-adren¬ 
alin in, 235 

block in carcinoma of neck, 237 
in epithelioma of lip, 218 
in excision of breast, 259 
in goiter, 242 

in intrathoracic toxic thyroid 
adenoma, 243 
in thyroidectomy, 237 
infiltration block of neck, 230 
nerves, anatomy of, 170 
Cesarean section, infiltration in, 503 
local anesthesia in, 502 
novocain-adrenalin in, 503 
Chloroform anesthesia, 26 

albuminuria and, 28 
arrhythmia and, 27 
cardiac disorders and, 27 
circulatory disorders and, 27 
cirrhosis of liver and, 28 
system and, 26 
dyspnea and, 27 


Chloroform anesthesia, enlarged bron¬ 
chial glands and, 27 
fatty degeneration of liver 
and, 26 

hepatic disorders and, 28 
renal disorders and, 28 
respiratory disorders and, 27 
thymus and, 27 
yellow atrophy of liver and, 28 
Cholecystectomy, anterior splanchnic 
anesthesia in, 452 
local anesthesia in, 441, 447, 448, 
449, 450, 451, 452, 454, 456 
infiltration in, 451 

Cholecystitis, local anesthesia in, 447, 
449, 450, 451, 452 

Choledochotomy, anterior splanchnic 
anesthesia in, 454 
infiltration block in, 455 
local anesthesia in, 453, 454, 456 
infiltration in, 454 
novocain-adrenalin in, 456 
Cholelithiasis, local anesthesia in, 447, 
449 

Ciliary nerves, anatomy of, 167 
Circulatory disorders, chloroform anes¬ 
thesia and, 27 

system, chloroform anesthesia and, 
26 

Circumcision, local anesthesia in, 341 
Circumferential block in transplanta¬ 
tion from tibia, 293 
infiltration anesthesia of Hacken- 
bruck, 112 

block in operations on brain, 
193 

of scalp, 187, 188, 189 
Clavicle, nerve supply of, 291 

surgery of, local anesthesia in, 291 
Cleft palate, local anesthesia in, 221, 
227 

Clitoris, dorsal nerve of, anatomy of, 
182 

nerve supply of, 349 
operations on, local anesthesia in, 
349 

Cocain as local anesthetic, 35 
Coccygeal nerves, anatomy of, 178 
Cold as local anesthetic, 33 
Colloid goiter, toxic, local anesthesia in, 
242 

Colostomy, local anesthesia in, technic 
of, 463 

Common peroneal nerve, anatomy of, 
180 

Conduction anesthesia, 111 

in surgery of female genitalia, 
345 

Congenital absence of vagina, infiltra¬ 
tion block in, 358 
local anesthesia in, 358 
novocain-adrenalin in,358 





INDEX 


515 


Congenital absence of vagina, sacral 
block in, 358 

stricture of male urethra, novo¬ 
cain-adrenalin in, 
340 

sacral anesthesia in, | 
340 

of urethra, local anesthesia in, 
339 

Costectomy, anesthesia in, technic of, 
263" 

local anesthesia in, 266 
Curettage, infiltration block in, 352 
local anesthesia in, technic of, 352 
Cutaneous cervical nerves, anatomy of, 

170 

Cyst, ovarian, anesthesia and operative 
technic in, 505 
local infiltration in, 505, 507 
novocain-adrenalin in, 505 
pelvic splanchnic anesthesia 
in, 505, 507 

of pancreas, local anesthesia in, 457 
infiltration in, 457 
Cystic adenoma of breast, 254 

local anesthesia in, 254 
duct clamp, 108 

Cystoscopy, local anesthesia in, 328 
sacral anesthesia in, 329 
Cystostomy, local anesthesia in, 326 
Cystotomy, air dilatation in, 329 
Cysts, aspiration of, local anesthesia 
in, 457 

of liver, local anesthesia in, 438 


D 

Decompression of brain, 191 
Deep perineal nerve, anatomy of, 180 
Denker’s operation in maxillary sinu¬ 
sitis, 202 

Dental nerve, inferior, anatomy of, 169 
Diabetes mellitus, ether anesthesia and, 
25 

Digital plantar nerve, anatomy of, 179 
Dislocations in children, reduction of, 
278 

of hip, local anesthesia in, 300 
infiltration in, 299 
novocain-adrenalin in, 299 
reduction of, technic of, 299 
reduction of, 276 

Dissection of neck, local anesthesia in, 
234 

Divulsion of sphincter, 366 
Dorsal antibrachial cutaneous nerve, 
anatomy of, 173 

nerve of clitoris, anatomy of, 182 
of penis, anatomy of, 182 
scapular nerve, anatomy of, 172 


Duodenal ulcer, anterior splanchnic 
anesthesia in, 425, 426 
infiltration block in, 423, 425, 
426 

local anesthesia in, 422, 423, 
425 


novocain-adrenalin in, 423 
Dupuytren’s contraction, infiltration 
block in, 297 
local anesthesia in, 297 
Dyspnea, chloroform anesthesia and, 27 


E 

Ear, surgery of, local anesthesia in, 194 
Ectopic pregnancy, novocain-adrenalin 
in, 502 

Elbow-joint, ankylosis of, brachial 
block in, 295 
local anesthesia in, 294 
infiltration in, 295 
saligenin in, 295 

arthroplasty of, local anesthesia 
in, 295 

nerve supply of, 294 
surgery of, local anesthesia in, 294 
Elliott’s incision in appendicitis, 475 
Empyema, intercostal block in, 266 
local anesthesia in, 266 
negative pressure in, 264 
novocain-adrenalin in, 266 
paravertebral block in, 266 
Enterostomy, local anesthesia in, 470 
Epigastric hernia, local anesthesia in, 
411 

Epinephrin as local anesthetic, 44 
Epithelioma of lip, cervical block in, 
218 

infiltration block in, 218 
local anesthesia in, 218, 236 
Equipment for local anesthesia, 82 

necessity for special, 82 
Ethanesal anesthesia, 25 
Ether anesthesia, 24 

anemias and, 25 
blood and, 24 

cardiovascular disease and, 25 
diabetes mellitus and, 25 
heart and, 24 
kidneys and, 24 
nephritis and, 25 
nervous system and, 24 
respiratory disorders and, 25 
Ethmoidal nerves, anatomy of, 167 
Excision of breast, 254 

local anesthesia in, 260, 261 
of mandible, local anesthesia in, 
219 

of palmar fascia, local anesthesia 
in, 297 




516 


INDEX 


Exophthalmic goiter, local anesthesia 
in, 245 

infiltration in, 245 
narco-local anesthesia in, 245 
quinin and urea hydrochloride 
in, 245 

External cutaneous nerve, anatomy of, 
176 

plantar nerve, anatomy of, 180 
popliteal nerve, anatomy of, 180 
respiratory nerve of Bell, anatomy 
of, 172 

spermatic nerve, anatomy of, 176 


F 

Face, anesthesia of, 198 
nerve supply of, 197 
nerves of, anatomy of, 166 
surgery of, local anesthesia in, 185, 
197' 

Facial nerve, anatomy of, 169 

Fallopian tubes, surgery of, local anes¬ 
thesia in, 500 

Farr’s automatic lifter, 102 

wire-spring retractor, 97 
“elephant trunk” operating room 
lamp, 95, 96, 97 
goiter clamp, 704 
method of anterior splanchnic 
anesthesia, 127 

needles for local anesthesia, 86 
for sacral anesthesia, 116 
pneumatic injector, 88 

detailed description of, 92 
operative mechanism of, 
93 

“setting-up” of, 93 
prostatic retractor, 105 
rubber-tipped intestinal forceps, 

no 

special bayonet-lock needle, 87 
subdermal method of anesthetiza¬ 
tion of skin line in introduc¬ 
tion of anesthetic solution, 150 
three-forceps and four-forceps tie, 
local anesthesia and, 156 
viscera retainer, 106 

Fascia, transplantation of, in incisional 
hernia, 407 

Fatty degeneration of liver, chloroform 
anesthesia and, 26 

Feet, surgery of, local anesthesia in, 271 

Female genitalia, external, anesthesia 

in, 345 

general considera¬ 
tions of, 345 
methods of obtain¬ 
ing, 345 

psychic considera¬ 
tions and, 346 


Female genitalia, external, anesthesia 
in, sacral, 345 
nerve supply of, 344 
Femoral hernia, anesthesia in, 406 

incarcerated, local infiltration 
in, 418 

novocain-adrenalin in, 
418 

nerve, anatomy of, 177 
Femur, fracture of, local anesthesia in, 
281, 282 . 
infiltration in, 299 
block in, 281 

novocain-adrenalin in, 281, 
282, 299 

transverse infiltration block 
in, 282 

ununited, local anesthesia in, 
299 

supracondyloid T-fracture of, local 
anesthesia in, 303 

Fibroid tumors of uterus, local infiltra¬ 
tion in, 507 

pelvic splanchnic anes¬ 
thesia in, 507 

Fingers, surgery of, local anesthesia in, 
272 

Fissures of anus, circumferential infil¬ 
tration in, 369 
sacral anesthesia in, 369 
Fistula-in-ano, circumferential infiltra¬ 
tion in, 369, 372 
infiltration block in, 370 
local anesthesia in, 372 
of intestine, tuberculous, local 
anesthesia in, 447 

Floating cartilages, infiltration block in, 
308 

local anesthesia in, 307 
novocain-adrenalin in, 308 
Fluoroscopic examinations, local anes¬ 
thesia and, 271 

Forearm, transverse infiltration block 
of, 274 

Fractional method, operating by, 80 
Fracture of base of skull, infiltration 
block in, 219 

in children, reduction of, 278 
malunited, 281 

of femur, closed operation, anes¬ 
thesia in, technic of, 302 
local anesthesia in, 281, 282 
infiltration in, 299 
block in, 281 

novocain-adrenalin in, 299, 
304 

open operation, anesthesia in, 
technic of, 303 

transverse infiltration block 
in, 303 

local infiltration block in, 
282 




INDEX 


517 


Fracture of femur, ununited, local 
anesthesia in, 299 
of humerus, oblique, brachial 
block in, 293 

of hip, reduction of, technic of, 299 
of leg, closed operation, anesthesia 
in, 308 

local anesthesia in, 309 
novocain-adrenalin in, 309 
sciatic nerve block in, 309 
transverse infiltration block 
in, 309 

of patella, local anesthesia in, 307 
Pott’s, local anesthesia in, 310 
novocain-adrenalin in, 310 
transverse infiltration block 
in, 310 

of radius and ulna, local anesthe¬ 
sia in, 279 

transverse infiltration 
block in, 279 
brachial block in, 278 
local anesthesia in, 278 
reduction of, 276 
of vault of skull, 190 
Fracture-dislocation of humerus, brach¬ 
ial block in, 293 
local anesthesia in, 293 
of shoulder-joint, brachial 
block in, 277 
local anesthesia in, 277 
infiltration in, 277 
Frontal nerve, anatomy of, 166 


G 

Gall-bladder, exposure of, 446 

posterior splanchnic anesthe¬ 
sia in, 446 

hydrops of, local anesthesia in, 448 
perforation of, local anesthesia in, 
447 

removal of, method of, 446 
novocain-adrenalin in, 446 
sensation of, 441 
surgery of, anterior splanchnic 
anesthesia in, 443 
local anesthesia in, 440 
opening of abdominal cavity 
in, 441 

negative intra-abdo¬ 
minal pressure in, 
441 

Gangrenous pneumonia, general anes¬ 
thesia and, 22 

Gasserian ganglion, injection of, 205 

Gastric ulcer, anterior splanchnic anes¬ 
thesia in, 424, 425 
local infiltration in, 424 
novocain-adrenalin in, 425 


Gastroenterostomy, anterior, local infil¬ 
tration in, 420 
novocain-adrenalin in, 420 
local anesthesia in, 420, 422, 426 
posterior, local infiltration in, 421, 
422 

novocain-adrenalin in, 421 
Gauze retractors, local anesthesia and, 
156 

Genito-urinary system, surgery of, local 
anesthesia in, 315 

Genitocrural nerve, anatomy of, 176 
Genitofemoral nerve, anatomy of, 176 
Glossopharyngeal nerve, anatomy of, 
169 

Goiter clamp, 104 

exophthalmic, local anesthesia in, 
245 

infiltration in, 245 
narco-local anesthesia in, 245 
quinin and urea hydrochloride 
in, 245 

toxic colloid, cervical block in, 242 
local anesthesia in, 242 
infiltration in, 242 
novocain-adrenalin in, 
242 

subdermal infiltration in, 
442 

Grant’s method of injecting the second 
and third division of trigeminal 
nerve, 205 

Great auricular nerve, anatomy of, 170 
sciatic nerve, anatomy of, 178 
Gunshot wound of abdomen, local 
infiltration in, 386 
novocain-adrenalin in, 
386 


H 

Hackenbruck, circumferential infiltra¬ 
tion anesthesia of, 112 

Hallux valgus, local anesthesia in, 
technic of, 311 

Hands, surgery of, local anesthesia of, 
271 

Hare-lip, local anesthesia in, 221, 227 
operations for, infiltration block 
in, 221 

Head, nerves of, anatomy of, 166 

surgery of, local anesthesia in, 185 

Heart, ether anesthesia and, 24 

Hemangioma of arm, local anesthesia 
in, 272 

of right brachium, local infiltration 
in, 272 

Hemorrhoidectomy, local anesthesia 
in, 413 

Hemorrhoids, circumferential infiltra¬ 
tion in, 369 


518 


INDEX 




Hemorrhoids, sacral anesthesia in, 369 
Hepatic disorders, chloroform anes¬ 
thesia and, 28 

Hernia epigastric, local anesthesia in, 

411 

femoral, anesthesia in, 406 

incarcerated, local infiltration 
in, 418 

novocain-adrenalin in, 
418 

incisional, anesthesia in, 406 

circumferential infiltration in, 
407 

local anesthesia in, 407 
novocain-adrenalin in, 407 
transplantation of fascia in, 
407 

inguinal, anesthesia in, induction 
of, 403 

infiltration block in, 406 
nerve supply of, 402 
novocain-adrenalin in, 406 
skin sterilization in, 403 
local anesthesia in, 402 
strangulated, local anesthesia in, 
415 

infiltration in, 417 
novocain-adrenalin in, 417 
umbilical, local anesthesia in, 411 
Herniotomy, local anesthesia in, 407 
Hip, ankylosis of, local anesthesia in, 
302 

arthritis of, local anesthesia in, 289 
arthroplasty of, local anesthesia 
in, 302 

infiltration in, 302 
nitrous oxide and oxygen in, 
302 

dislocation of, local anesthesia in, 
300 

infiltration in, 299 
novocain-adrenalin in, 299 
reduction of, technic of, 299 
fractures of, reduction of, technic 
of, 299 

nerve supply of, 297 
surgery of, local anesthesia in, 297 
open operations, tech¬ 
nic of, 298 

Hour-glass contraction of stomach, 
local anesthesia in, 427 
stomach, sleeve resection for, local 
infiltration, 427 

Humerus, fracture of, brachial block 
in, 293 

novocain-adrenalin in, 294 
fracture-dislocation of, brachial 
block in, 293 
local anesthesia in, 293 
novocain-adrenalin in, 293 
Hydrocele, local anesthesia in, 342 
subdermal infiltration in, 344 


Hydrops of gall-bladder, local anes¬ 
thesia in, 448 

Hydropyo-ureter, double, local anes¬ 
thesia in, 326 
infiltration in, 326 
novocain-adrenalin in, 328 
paravertebral block in, 326 
sacral block in, 326 
Hymen, atresia of, infiltration block 
in, 352 

local anesthesia in, 357 
Hypertrophic pyloric stenosis, local 
anesthesia in, 430 
infiltration in, 436 
novocain-adrenalin in, 437 
Hypertrophy of prostate, local anes¬ 
thesia in, 335, 337 
infiltration in, 335, 336, 
337 

morphine in, 335 
narco-local anesthesia in, 335 
novocain-adrenalin in, 335, 
336, 338 

quinin and urea hydrochlor¬ 
ide in, 335 

sacral block in, 336, 337 
scopolamin in, 335 

Hypodermoclysis in local anesthesia, 
'166 

Hypogastric nerve, anatomy of, 176 
Hypospadias, local anesthesia in, 341 
Hysterectomy, abdominal, novocain- 
adrenalin in, 498 
pantopon in, 498 
sacral anesthesia in, 498 
scopolamin in, 498 
local anesthesia in, 505, 507 
vaginal, local anesthesia in, tech¬ 
nic of, 356 
infiltration in, 357 
novocain-adrenalin in, 357 
quinin and urea hydrochloride 
in, 357 

Hysteropexy, local anesthesia in, 450, 
451, 495 

preliminary packing of vaginal 
vault in, 496 


I 


Iliac nerve, 176 

Iliohypogastric nerve, anatomy of, 175 
Ilioinguinal nerve, anatomy of, 176 
Incarcerated femoral hernia, local 
infiltration in, 418 
novocain-adrenalin in, 
418 

Incisional hernia, anesthesia in, 406 
circumferential infiltration in, 
407 

novocain-adrenalin in, 407 



INDEX 


519 


Incisional hernia, transplantation of 
fascia in, 407 

Inferior alveolar nerve, anatomy of, 169 
dental nerve, anatomy of, 169 
hemorrhoidal nerve, anatomy of, 
182 

maxillary nerve, anatomy of, 168 
Infiltration, abdominal, in appendicec- 
tomy, 481 

wall, direct, in calculi of 
ureter, 325 
in pyonephrosis, 325 
in pyoureter, 325 
anesthesia, 111 

advantages of, 139 
direct versus regional, 137 
technic of, 144 
block, 112 

in atresia of hymen, 358 
in congenital absence of 
vagina, 358 

circumferential, in chronic 
osteomyelitis, 290 
in curettage, 352 
in duodenal ulcer, 423, 425, 
426 

in Dupuytren’s contraction, 
297 

in epithelioma of lip, 218 
in fistula-in-ano, 370 
in floating cartilages, 308 
in fracture of base of skull, 219 
of femur, 281 
in inguinal hernia, 403 
in interposition operations on 
uterus, 354 
in laminectomy, 268 
of neck, cervical, 230 
subdermal, 232 
in nephrolithiasis, 323 
operations on brain, 193 
for hare-lip, 221 
in perineorrhaphy, 349 
in prolapse of uterus, 356 
in pyonephrosis, 322 

in rupture of kidney, 323 
of scalp, 187, 188, 189 
in tonsillectomy, 222 
transverse, in amputation of 
leg, 287, 288 
of arm, 274 
of forearm, 274 
in fracture of femur, 282 
of leg, 309 
of radius and ulna, 
279 

in Pott’s fracture, 310 
of thigh, 275, 276 
in tumors of breast, 252 
of spinal cord, 269 
cervical block, in carcinoma of 
neck, 237 


Infiltration, cervical block, in thyroid¬ 
ectomy, 237 

circumferential, in carcinoma of 
breast, 261 

in fissures of anus, 369 
in fistula-in-ano, 369, 372 
in hemorrhoids, 369 
in incisional hernia, 407 
in polypi of rectum, 369 
in prolapse of rectum, 375, 377 
in surgery of anus, 363 
of rectum, 363 
deep, in appendicitis, 476 
in laryngectomy, 246 
in thyroidectomy, 237 
local, in ankylosis of elbow-joint, 
295 

in anterior gastroenterostomy, 
420 

in appendicectomy, 481 
in arthroplasty of hip, 302 
in carcinoma of breast, 260 
of lip, 236 
of rectosigmoid, 462 
in Cesarean section, 503 
in choledochotomy, 454 
in cyst of pancreas, 457 
in dislocation of hip, 299 
in exophthalmic goiter, 245 
in fibroid tumors of uterus,507 
in fracture of femur, 299 
in fractures of patella, 307 
in fracture-dislocation of 
shoulder-joint, 277 
in gastric ulcer, 424 
in gunshot wound of abdo¬ 
men, 386 

in hemangioma of right brach- 
ium, 272 

in hydropyo-ureter, 326 
in hypertrophic pyloric sten¬ 
osis, 436 

in hypertrophy of prostate, 
335, 336, 337 

in incarcerated femoral hernia, 
418 

in incomplete abortion, 353 
in intrathoracic toxic thyroid 
adenoma, 243 

in intussusception in children, 
465, 466 

on leg, in transplantation from 
tibia, 283 

in operations on palate, 228 
in ovarian cyst, 505, 507 
in panhysterectomy, 499, 520 
in pelvic abscess, 360 
in posterior gastroenteros¬ 
tomy, 421, 422 
in prolapse of rectum, 376 
in pulmonary abscess, 217 
in pyosalpinx, 501 





520 


INDEX 


Infiltration, local, in resection for car¬ 
cinoma of stomach, 429 
in sleeve resection for hour¬ 
glass stomach, 427 
in strangulated hernia, 417 
in toxic colloid goiter, 242 
in tuberculous peritonitis, 467, 
468 

in vaginal hysterectomy, 357 
in varicose veins of leg, 314 
meso-appendix, in appendicitis,478 
midline, in carcinoma of breast,261 
subdermal, in appendicitis, 476 
in excision of breast, 259 
in hydrocele, 344 
in laminectomy, 268 
in laryngectomy, 247 
in toxic colloid goiter, 242 
in tumors of breast, 252 
in varicocele, 342 
superficial, in laryngectomy, 246 
in thyroidectomy, 237 
suprapubic in vesical calculus, 330 
transverse, in fracture of femur,303 
Infratrochlear nerve, anatomy of, 167 
Inguinal hernia, anesthesia in, induc¬ 
tion of, 403 

infiltration block in, 406 
nerve supply of, 402 
novocain-adrenalin in, 406 
sterilization of skin in, 403 
Intercostal block in carcinoma of 
breast, 261 
in empyema, 266 
in resection for carcinoma of 
stomach, 429 
nerves, anatomy of, 173 
Intercosto-brachial nerve, anatomy of, 
174 

Intermediate dorsal cutaneous nerve, 
anatomy of, 181 

Internal calcaneal nerve, anatomy of, 
179 

cutaneous nerve, anatomy of, 177 
plantar nerve, anatomy of, 179 
popliteal nerve, anatomy of, 179 
pudic nerve, anatomy of, 182 
saphenous nerve, anatomy of, 177 
Intestinal forceps, 110 
Intestine, resection of, local anesthesia 
in, 467 

tuberculous fistula of, local anes¬ 
thesia in, 467 

Intestines, carcinoma of, resection for, 
local anesthesia in, 460 
surgery of, local anesthesia in, 459 
diagnosis and, 459 
special considera¬ 
tions of, 459 
in treatment of com¬ 
plicated condi¬ 
tions, 459 


Intestines, surgery of, local anesthesia 
in treatment of simple conditions, 
459 

Intra-abdominal abscess, drainage of, 
technic of, 484 

pelvic infiltration and blocking, 
technic of, 494 

pressure, negative, in introduction 
of anesthetic solution, 
153 

in opening of abdomen in 
appendicitis, 
478 

in surgery of the 
gall - bladder, 
441 

Intradermal method of anesthetization 
of skin line in introduction of anes¬ 
thetic solution, 149 
Intraneural anesthesia, 111 
Intraperitoneal pain sense, 379 
Intraspinal anesthesia, 111 
Intrathoracic toxic thyroid adenoma, 

cervical block in, 
243 

local infiltration in, 
243 

saligenin in, 243 

Intussusception in children, local infil¬ 
tration in, 465, 466 
McArthur incision in, 465 
novocain-adrenalin in, 465, 
466 

local anesthesia in, 464, 465, 466 
saligenin in, 464 

K 

Kidney, functionless, local anesthesia 
in, 326 

nerve supply of, 316 
rupture of, local anesthesia in, 323 
infiltration block in, 323 
novocain adrenalin in, 323 
surgery of, local anesthesia in, 316 
delivery of kidney 
and, 32 

incision and, 320 
sensation and, 319 
technic of, 317 

suture of, local anesthesia in, 323 
Kidneys, ether anesthesia and, 24 
Knee-joint, loose cartilage in, local 
anesthesia in, 308 
nerve supply of, 305 
surgery of, local anesthesia in, 305 
technic of, 306 

L 

Labia, nerve supply of, 348 

operations on, local anesthesia in, 
technic of, 348 




INDEX 


521 


Labial nerves, anatomy of, 168 
Lacrimal nerve, anatomy of, 166 
Laminectomy, anesthesia in, technic 
of, 268 

infiltration block in, 268 
local anesthesia in, 270 
subdermal infiltration in, 268 
Laparotomy, local anesthesia in, 465, 
466 


Laryngeal nerves, anatomy of, 169, 170 
polypi, local anesthesia in, 248 
Laryngectomy, anesthesia in, deep infil¬ 
tration, 246 

subdermal infiltration in, 247 
superficial infiltration in, 246 
technic of, 246 
local anesthesia in, 248, 249 
novocain-adrenalin in, 249 
pantopon in, 249 
scopolamin in, 249 

Laryngotomy, local anesthesia in, 248 
Larynx, carcinoma of, infiltration block 
in, 249 

local anesthesia in, 249 
novocain-adrenalin in, 249 
pantopon in, 249 
scopolamin in, 249 
nerve supply of, 246 
Lateral femoral cutaneous nerve, anat¬ 
omy of, 176 

plantar nerve, anatomy of, 180 
sural cutaneous nerve, anatomy 
of, 180 

Leg, amputation of, local anesthesia 
in, 287, 288 

novocain-adrenalin in, 288 
transverse infiltration block 
in, 287, 288 

fractures of, closed operations, 
anesthesia in, 308 
local anesthesia in, 309 
novocain-adrenalin in, 309 
sciatic nerve block in, 309 
transverse infiltration block 
in, 309 

surgery of, local anesthesia in, 308 
varicose ulcer of, local anesthesia 
in, 288 

veins of, local anesthesia in, 
312, 314 

novocain-adrenalin in,314 
Ligation of thyroid arteries, 243 
technic of, 243 

Ligatures, tying of, local anesthesia 
and, 154 

Lingual nerve, anatomy of, 169 
blocking of, 224 

Lip, carcinoma of, block dissection for, 
236 


local infiltration in, 236 
epithelioma of, cervical block in, 
218 


Lip, epithelioma of, infiltration block 
in, 218 

local anesthesia in, 218, 236 
Lipectomy, local anesthesia in, 411, 413 
Liver, abscess of, local anesthesia in, 
438 

cysts of, local anesthesia in, 438 
fatty degeneration of, chloroform 
anesthesia and, 26 
rupture of, local anesthesia in, 438 
yellow atrophy of, chloroform 
anesthesia and, 28 

Lobectomy, local anesthesia in, 242, 
243, 245 

Long buccal nerve, anatomy of, 169 
ciliary nerve, anatomy of, 167 
saphenous nerve, anatomy of, 177 
thoracic nerves, anatomy of, 172 
Lumbar nerves, anatomy of, 175 
Lumboinguinal nerve, anatomy of, 176 
Lungs, abscess of, general anesthesia 
and, 22 


M 

McArthur’s gridiron incision in 
appendicitis, 472 

incision in intussusception in chil¬ 
dren, 465 

Malunited fractures in children, reduc¬ 
tion of, 281 

Mandible, excision of, local anesthesia 
in, 219 

Mandibular nerve, anatomy of, 168 
blocking of, 202 

injections at mandibular 
division, 209 
subzygomatic injection at 
maxillary division of, 
208 

transoral, 216 

Masseteric nerve, anatomy of, 169 
Mastitis, suppurative, anesthesia for 
drainage, technic of, 254 
Mastoid operations, infiltration block 
for, 194 

novocain-adrenalin in, 196 
Mastoiditis, subacute, local anesthesia 
in, 196 

Maxilla, inferior, alveolar process of, 

carcinoma of, 217 
excision of glands of 
neck in, 217 
resection of inferior 
maxilla in, 217 

carcinoma of, local anesthesia 
in, 219 

excision of, anesthesia for, 215 
superior, excision of, anesthesia 
for, 214 

Maxillary nerve, blocking of, 200 
nerves, anatomy of, 167, 168 











522 


INDEX 


Maxillary sinusitis, Denker’s oper¬ 
ation in, local anesthesia in, 202 
Moynihan’s cystic duct clamp, 108 
Medial calcaneal nerve, anatomy of, 

179 

plantar nerve, anatomy of, 179 
sural cutaneous nerve, anatomy of, 
179 

Median nerve, anatomy of, 172 
Meningeal nerves, anatomy of, 167 
Middle cutaneous nerve, anatomy of, 

177 

dorsal cutaneous nerve, anatomy 
of, 181 

meningeal nerve, anatomy of, 167 
supraclavicular nerve, anatomy 
of, 172 

Mouth, surgery of, local anesthesia in, 
222 

Musculocutaneous nerve, anatomy of, 

181 

Musculospiral nerve, anatomy of, 173 
Myomectomy, local anesthesia in, 376, 
496 


Narco-local anesthesia, 72 
technic of, 132 
Narcotics, preliminary, 72 
Nasal nerves, anatomy of, 168 
Nasociliary nerve, anatomy of, 167 
Neck, anesthesia of, methods of indu¬ 
cing, 230 

carbuncle of, infiltration block in, 
237 

local anesthesia in, 236 
deep cervical infiltration block of, 
230 

dissection of, local anesthesia in, 
234 

malignant disease of, 232 
nerve supply of, 229 
subdermal infiltration block in, 232 
surgery of, local anesthesia in, 229 
advantages of, 229 
cooperationof patient 
and, 229 

tuberculous glands of, 232 
Needles for local anesthesia, 86 
Negative intra-abdominal pressure in 

opening of abdomen 
in appendicitis,478 
in surgery of gall¬ 
bladder, 441 
of abdominal wall, 153 
Nephrectomy, local anesthesia in, 319, 
322, 526 

Nephritis, ether anesthesia and, 25 
Nephrolithiasis, infiltration block in, 
322 

local anesthesia in, 319, 322 


Nephrolithiasis, morphin in, 319 
novocain-adrenalin in, 322 
paravertebral block in, 319, 322 
scopolamin in, 319 

Nephro-ureterectomy, local anesthesia 
in, 326 

Nerve or Nerves, accessory obturator, 

177 

alveolar, 168 
anococcygeal, 182 
anterior crural, 177 
thoracic, 172 
tibial, 181 
of Arnold, 170 
auricular, 170 
auriculotemporal, 169 
buccinator, 169 
cervical, 170 
coccygeal, 178 
common peroneal, 180 
cutaneous cervical, 170 
deep peroneal, 181 
digital plantar, 179, 180 
dorsal antibrachial cutaneous, 173 
of clitoris, 182 
of penis, 182 
scapular, 172 
ethmoidal, 167 
external cutaneous, 176 
plantar, 180 
popliteal, 180 
respiratory of Bell, 172 
spermatic, 176 
facial, 169 
femoral, 177 
frontal, 166 
genitocrural, 176 
genitofemoral, 176 
glossopharyngeal, 169 
great auricular, 170 
sciatic, 178 
hypogastric, 176 
iliac, 176 

iliohypogastric, 175 
ilioinguinal, 176 
inferior alveolar, 169 
dental, 169 
hemorrhoidal, 182 
maxillary, 168 
infratrochlear, 167 
intercostal, 173 
intercosto-brachial, 174 
intermediate dorsal cutaneous, 181 
internal calcaneal, 179 
cutaneous, 177 
plantar, 179 
popliteal, 179 
pudic, 182 
saphenous, 177 
labial, 168 
lacrimal, 166 
laryngeal, 169, 170 



INDEX 


523 


Nerve or Nerves, lateral femoral cuta¬ 
neous, 176 
plantar, 180 
sural cutaneous, 180 
lingual, 169 

blocking of, 224 
long buccal, 169 
ciliary, 167 
saphenous, 177 
thoracic, 172 
lumbar, 175 
lumboinguinal, 176 
mandibular, 168 

blocking of, 202 
transoral, 216 
masseteric, 169 
maxillary, 167 

blocking of, 200 
meatus auditorii externi, 169 
medial calcaneal, 179 
plantar, 179 
sural cutaneous, 179 
median, 172 
middle cutaneous, 177 
dorsal cutaneous, 181 
meningeal, 167 
supraclavicular, 172 
musculocutaneous, 181 
musculospiral, 173 
nasal, 168 
nasociliary, 167 
ninth, 169 
obturator, 177 
occipital, 170 
ophthalmic, 166 

blocking of, 198 
palatine, 168 
palpebral, 168 
perforating, cutaneous, 182 
perineal, 178, 182 
peroneal, 180 
plexus of, brachial, 172 
celiac, 183 
cervical, 170 
lumbosacral, 175 
pudendal, 181 
sacral, 175 
solar, 183 

pneumogastric, 169 
posterior brachial cutaneous, 173 
femoral cutaneous, 178 
scapular, 172 
scrotal, 182 
thoracic, 172 
pudendal, 182 
radial, 173 

recurrent laryngeal, 170 
sacral, 178 

anesthesia of, 117 
saphenous, 177 
sciatic, 178 
seventh, 169 


Nerve or Nerves, small sciatic, 178 
smaller occipital, 170 
spinal, 170 

superficial cervical, 170 
perineal, 182 
peroneal, 181 

supply of abdominal wall, 379 
of ankle-joint, 310 
of anus, 363 
of clitoris, 349 
of clavicle, 291 
of elbow-joint, 294 
of external genitalia of female, 
344 

of face, 197 
of head, 166 
of hip, 297 

of inguinal hernia, 402 
of kidney, 316 
of knee-joint, 305 
of labia, 348 
of larynx, 246 
of neck, 229 
of palate, 226 
of penis, 340 
of perineum, 349 
of peritoneum, 379 
of rectum, 363 
of scalp, 185 
of shoulder, 291 
of spine, 267 

of sympathetic system, 182 
of thyroid gland, 237 
of tongue, 224 
of tonsil, 222 
of uterus, 352 
of wrist, 297 
supra-acromial, 172 
supraclavicular, 171 
supraorbital, 167 
suprascapular, 172 
suprasternal, 172 
supratrochlear, 167 
tenth, 169 
thoracic, 261 

thoracico-abdominal intercostal, 
175 

tibial, 179 

transverse cervical, 170 
trigeminal, 166 

blocking of, 198 
ulnar, 173 
vagus, 169 
of Wrisberg, 169 
zygomaticofacialis, 168 
Nervous system, ether anesthesia and 
24 

Neuritis, optic, local anesthesia in, 
193 

New growths of scalp, 190 
Nitrous oxide anesthesia, 28 
Ninth nerve, anatomy of, 169 




524 


INDEX 


Nirvanin as local anesthetic, 39 
Novocain (procain) as local anesthetic, 
45 

O 

Obturator nerve, anatomy of, 177 
Occipital nerves, anatomy of, 170 
Operating by fractional method, 80 
room, lighting of, 95 
table for local anesthesia, 83 
Ophthalmic nerve, anatomy of, 166 
blocking of, 198 
deep, 199 

Optic neuritis, local anesthesia in, 193 
Orchidectomy, local anesthesia in, 235, 
342 

Osteomyelitis, acute, local anesthesia in 
in, technic for drainage in, 290 
chronic, circumferential infiltra¬ 
tion block in, 290 
novocain-adrenalin in, 290 
of tibia, local anesthesia in, 290 
Ovarian cyst, anesthesia and operative j 
technic in, 505 
local infiltration in, 305, 507 
novocain-adrenalin in, 505 
pelvic splanchnic anesthesia 
in, 505, 507 

Ovaries, surgery of, local anesthesia 
in, 503 

P 

Palate, cleft, local anesthesia in, 221, 
227 

nerve supply of, 226 
operations on, anesthesia for, 226 
local infiltration in, 228 
Palatine nerves, anatomy of, 168 
Palmar fascia, excision of, local anes¬ 
thesia in, 297 

Palpebral nerves, anatomy of, 168 
Pancreas, cyst of, local anesthesia in, 
457 

infiltration in, 457 
surgery of, local anesthesia in, 457 
Panhysterectomy, anterior splanchnic 
anesthesia in, 499 
local infiltration in, 499, 500 
novocain-adrenalin in, 500 
pelvic splanchnic anesthesia in, 
500 

Parasacral anesthesia in carcinoma of 
rectum, 373 

in pelvic operations, 493 
technic of, 119 

Paravertebral anesthesia, technic of, 
122 

block in empyema, 266 

in hydropyo-ureter, 326 
in nephrolithiasis, 319, 322 


Paravertebral block in pulmonary ab¬ 
scess, 267 

in pyonephrosis, 322 
in ureterolithiasis, 319 
Patella, fracture of, local anesthesia 
in, 307 

infiltration in, 307 
novocain-adrenalin in, 307 
Pedicle flaps in skin-grafting, local 
anesthesia in, 164 

Pelvic abscess, local anesthesia in, 360 
infiltration in, 367 
sacral anesthesia in, 361 
laparotomy, local anesthesia in, 358 
operations, adjuncts to, 492 

anterior splanchnic anesthesia 
in, 494 

incisions in, 489 
parasacral anesthesia in, 493 
sacral anesthesia in, 493 
trans-sacral anesthesia in, 493 
splanchnic anesthesia in panhys¬ 
terectomy, 500 
Pelvis, blocking of, 489 
exposure of, 489 

abdominal incision in, 490, 
491 

surgery of, local anesthesia in, 489 
skin sterilization in, 
489 

Penis, amputation of, local anesthesia 
in, 341 

dorsal nerve of, anatomy of, 182 
nerve supply of, 340 
surgery of, local anesthesia in, 340 
Perforating cutaneous nerve, anatomy 
of, 182 

Perforation of gall-bladder, local anes¬ 
thesia in, 447 

Perineal nerve, anatomy of, 178, 182 
prostatectomy, local anesthesia in, 
338 

Perineorrhaphy, infiltration block in, 
349 

local anesthesia in, 355, 413 
technic of, 349 

Perineum, nerve supply of, 349 

operations on, local anesthesia in, 
349 

Perineural anesthesia, 111 
Peritoneum, nerve supply of, 379 
Peritonitis ileus, local anesthesia in, 470 
tuberculous, local anesthesia in, 
467 

Peroneal nerves, anatomy of, 180 
Phenol as local anesthetic, 34 
Plexus of nerves, brachial, anatomy of, 
172 

celiac, anatomy of, 182 
cervical, anatomy of, 170 
lumbosacral, anatomy of, 175 
pudendal, anatomy of, 181 







INDEX 




Plexus of nerves, sacral, anatomy of, I 
175 

solar, anatomy of, 182 
Pneumatic injector, 88 

detailed description of, 92 
operative mechanism of, 93 
Pneumogastric nerve, anatomy of, 169 
Pneumonia, gangrenous, general anes¬ 
thesia and, 22 
Pneumoperitoneum, 399 
Polypi, laryngeal, local anesthesia in, 
248 

rectal, circumferential infiltration 
in, 369 

sacral anesthesia in, 369 
Posterior brachial cutaneous nerve, 
anatomy of, 173 

femoral cutaneous nerve, anatomy 
of, 178 

scapular nerve, anatomy of, 172 
scrotal nerve, anatomy of, 182 
thoracic nerve, anatomy of, 172 
Postoperative drainage, local anes¬ 
thesia and, 507 

shock, general anesthesia and, 20 
Pott’s fracture, local anesthesia in, 310 
novocain-adrenalin in, 310 
transverse infiltration block 
in, 310 

Pratt’s rectal dilators, 109 
Pregnancy, ectopic, novocain-adrenalin 
in, 502 

Pressure as local anesthetic, 34 
Prolapse of rectum, circumferential 
infiltration in, 375, 377 
local anesthesia in, 375 
infiltration in, 376 
novocain-adrenalin in, 376 
quinin and urea hydrochlor¬ 
ide in, 375 

sacral anesthesia in, 373 
of uterus, infiltration block in, 356 
local anesthesia in, 355 
novocain-adrenalin in, 356 
Prostate, hypertrophy of, local anes¬ 
thesia in, 335, 337 
infiltration in, 335, 336, 
337 

morphin in, 335 
narco-local anesthesia in, 335 
novocain-adrenalin in, 335, 
336, 338 

quinin and urea hydrochlor¬ 
ide in, 335 

sacral block in, 336, 337 
scopolamin in, 335 

Prostatectomy, perineal, local anes¬ 
thesia in, 338 

suprapubic, local anesthesia in, 331 
prostatic retractor in, 332 
sacral anesthesia in, 331 
Prostatic “hook,” 108 


Prostatic retractor, 105 

in suprapubic prostatectomy, 
332 

Psycho-anesthetist, local anesthesia 
and, 160 

Psycho-local anesthesia, 79 
Pudendal nerve, anatomy of, 182 
Pulmonary abscess, local anesthesia 
in, 266 

infiltration in, 267 
paravertebral block in, 267 
Pylorectomy, local anesthesia in, 425 
Pyloric stenosis, hypertrophic, local 

anesthesia in, 430 
infiltration in, 436 
novocain-adrenalin in, 
437 

Pyloroplasty, local anesthesia in, 421, 
447 

Pylorus, cancer of, local anesthesia in, 
420 

Pyonephrosis, direct infiltration of ab¬ 
dominal wall in, 325 
infiltration block in, 322 
local anesthesia in, 322, 325 
novocain-adrenalin in, 322 
paravertebral block in, 362 
Pyosalpinx, anterior splanchnic anes¬ 
thesia in, 501 

Pyoureter, direct infiltration of abdomi¬ 
nal wall in, 325 
local anesthesia in, 325 
novocain-adrenalin in, 325 


Q 

Quinin and urea hydrochloride as 
local anesthetic, 40 


R 

Radial nerve, anatomy of, 173 
Radius and ulna, fracture of, local anes¬ 
thesia in, 279 
novocain-adrenalin in, 
275 

transverse infiltration 
block in, 279 

fracture of, brachial block in, 
278 

local anesthesia in, 278 
Radiographic examinations, local anes¬ 
thesias and, 271 

Rammstedt pyloric incision, local anes¬ 
thesia in, 436, 437 
Rectal dilators, 109 
Rectosigmoid, carcinoma of, circumfer¬ 
ential infiltration in, 463 
local infiltration in, 462 
novocain-adrenalin in, 462 






526 


INDEX 


Rectosigmoid, carcinoma of, sacral 
anesthesia in, 463 

Rectum, carcinoma of, parasacral anes¬ 
thesia in, 373 
sacral anesthesia in, 373 
trans-sacral anesthesia in, 373 
examination of, 368 
nerve supply of, 363 
polypi of, circumferential infiltra¬ 
tion in, 369 

sacral anesthesia in, 369 
prolapse of, circumferential infil¬ 
tration in, 375, 377 
local anesthesia in, 375 
infiltration in, 376 
novocain-adrenalin in, 376 
quinin and urea hydrochlor¬ 
ide in, 375 

sacral anesthesia in, 373 
surgery of, circumferential infil¬ 
tration in, 363 
local anesthesia in, 362 

choice of methods 
362 

position of patient 
in, 362 

postoperative comfort in, 377 
Recurrent laryngeal nerve, anatomy 
of, 170 

Regional anesthesia, 111 

application of, 136 

Renal disorders, chloroform anesthesia 
and, 28 

Resection of intestine, local anesthesia 
in, 467 

of stomach, local anesthesia in, 
429 

Respiration, general anesthesia and, 19 
Respiratory disorders, chloroform anes¬ 
thesia and, 27 
ether anesthesia and, 25 
nerve of Bell, anatomy of, 172 
Ribs, resection of, anesthesia in, 264 

subdermal infiltration in, 265 
Rupture of kidney, local anesthesia in, 
323 

of liver, local anesthesia in, 438 


S 

Sacral anesthesia in abdominal hys¬ 
terectomy, 498 
in carcinoma of rectosigmoid, 
463 

of rectum, 373 

in congenital absence of vagina, 
358 

in cystoscopy, 329 
Farr’s needles for, 116 
in fissure of anus, 369 
in fistula-in-ano, 369 


Sacral anesthesia in hemorrhoids, 369 
in hydropyo-ureter, 326 
in hypertrophy of prostate, 
336, 337 

in pelvic abscess, 361 
operations, 493 
in prolapse of rectum, 373 
in rectal polypi, 369 
in surgery of appendix, 471 
of female genitalia, 345 
technic of, 115 
two-needle method, 116 
nerves, anatomy of, 178 
anesthesia of, 117 

Saligenin (salicain) as local anesthetic, 
42 

Salpingectomy, local anesthesia in, 502 
Saphenous nerve, anatomy of, 177 
Scalp, anesthesia of, 186 
duration of, 189 
atheromata of, 190 
circumferential infiltration block 
of, 187, 188, 189 
nerve supply of, 185 
new growths of, excision of, 190 
Scapular nerves, anatomy of, 172 
Sciatic nerve, anatomy of, 178 

block in fractures of leg, 309 
Sensory nervous system, anatomy of, 
166 

Seventh nerve, anatomy of, 169 
Shock, postoperative, general anes¬ 
thesia and, 20 

Shoulder, nerve supply of, 291 

surgery of, local anesthesia in, 291 
Shoulder-joint, fracture-dislocation of, 
brachial block in, 277 
local anesthesia in, 277 
infiltration in, 277 
novocain-adrenalin in, 277 
subluxation of, brachial block in, 
293 

local anesthesia in, 293 
Sinusitis, maxillary, Denker’s operation 
in, local anesthesia in, 202 
Skin, incision of, in introduction of 
anesthetic solution, 153 
line, anesthetization of, in intro¬ 
duction of anesthetic solution, 
149 

plastics, local anesthesia in, 221 
sterilization of, in inguinal hernia, 
403 

in surgery of pelvis, 489 
in varicocele, 342 

Skin-grafting, local anesthesia in, 163 
Skull, base of, fracture of, infiltration 
block in, 219 

surgery of , local anesthesia in, 190 
vault of, fractures of, 190 
Sleeve resection for hour-glass stomach, 
427 




INDEX 


527 


Small sciatic nerve, anatomy of, 178 
Smaller occipital nerve, anatomv of, 
( 170 

Solar plexus, anatomy of, 182 
Sphincter, clivulsion of, 366 
Spinal cord, tumor of, infiltration block 
in, 269 

local anesthesia in, 269, 
270 

nerves, anatomy of, 170 
Spine, nerve supply of, 267 

surgery of, local anesthesia in, 251, 
267' 

Splanchnic anesthesia, technic of, 124 
anterior, 125 
posterior, 124 

Spleen, anterior splanchnic anesthesia 
of, 458 

surgery of, local anesthesia in, 458 
Sponging, local anesthesia and, 154 
Steinman pin, introduction of, technic 
^ of, 311 

Stenosis, hypertrophic pyloric, local 

anesthesia in, 430 
infiltration in, 436 
novocain-adrenalin in, 
437 


Subtemporal decompression, 193 
infiltration block in, 193 
novocain-adrenalin in, 193 
Subzygomatic injection at maxillary 
division of mandibular nerve, 208 
Superficial cervical nerve, anatomy of, 
170 

perineal nerve, anatomy of, 182 
peroneal nerve, anatomy of, 181 
Suppurative arthritis, local anesthesia 
in, technic of, drainage in, 289 
cervical adenitis, novocain-adren¬ 
alin in, 233 

mastitis, anesthesia for drainage, 
technic of, 254 

Supra-acromial nerves, anatomy of, 172 
Supraclavicular nerves, anatomy of, 

171 

Supracondyloid T-fracture of femur, 
local anesthesia in, 303 
Supraorbital nerve, anatomy of, 167 
Suprapubic cystotomy, local anesthesia 

in, 325, 329, 330, 
335, 336 
technic of, 329 
method of opening bladder in, 
329 


Stomach, carcinoma of, local anes¬ 
thesia in, 429 

resection for, anterior splanch¬ 
nic anesthesia in, 429 
intercostal block in, 429 
local infiltration in, 429 
novocain-adrenalin in, 429 
hour-glass contraction of, local 
anesthesia in, 427 
sleeve resection for, local infil¬ 
tration in, 427 

operations on, avoidance of clamps 
in, 420 

local anesthesia in, 419 
resection of, local anesthesia in, 
429 

Stovain as local anesthetic, 37 
Strangulated hernia, local anesthesia 
in, 415 

infiltration in, 417 
novocain-adrenalin in, 417 
Stricture of male urethra, congenital, 

novocain-adrenalin 
in, 340 

sacral anesthesia in, 
340 

multiple, local anesthesia 
in, 339 

novocain-adrenalin in, 
339 

Subdermal infiltration block of neck, 
232 

Subluxation of shoulder-joints, brachial 
block in, 293 
local anesthesia in, 293 


prostatectomy, local anesthesia in, 
331 

prostatic retractor in, 332 
sacral anesthesia in, technic 
of, 331 

Suprascapular nerves, anatomy of, 172 
Suprasternal nerves, anatomy of, 172 
Supratrochlear nerve, anatomy of, 167 
Suprazygomatic injection at maxillary 
division of mandibular nerve, 208 
Sympathetic nervous system, anatomy 
' of, 182 

Synergistic anesthesia, technic of, 133 
Syringes for local anesthesia, 85 


T 

T-fracture of femur, supracondyloid, 
local anesthesia in, 303 

Tenth nerve, anatomy of, 169 

Thoracico-abdominal intercostal nerve, 
anatomy of, 175 

Thiersch’s method of skin-grafting, 
local anesthesia in, 163 

Thigh, transverse infiltration block of, 
275, 276 

Thoracentesis, anesthesia in, technic 
of, 262 

Thoracic nerves, 261 

anatomy of, 172, 173 

Thorax, surgery of, local anesthesia in, 
in, 251, 261 ' 

Throat, surgery of, local anesthesia in, 
222 





528 


INDEX 


Thymus, enlarged, chloroform anes-j 
thesia and, 27 

Thyroid adenoma, intrathoracic toxic, 

cervical block in, 
243 

local infiltration in, 
243 

saligenin in, 243 
arteries, ligation of, 243 
gland, nerve supply of, 237 
Thyroidectomy, anesthesia for, 238 
in non-toxic cases, anesthetic tech¬ 
nic, 237 

cervical block, 237 
deep infiltration in, 237 
surgical technic, 237 
superficial infiltration in, 
237 

in toxic cases, 243 
Thyroids, toxic, 243 
Tibia, osteomyelitis of, local anesthesia 
in, 290 

Tibial nerve, anatomy of, 179 
Toe, amputation of, local anesthesia 
in, 314 

Toes, surgery of, local anesthesia in, 272 
Tongue, nerve supply of, 224 

surgery of, local anesthesia in, 224 
Tonsil, nerve supply of, 222 
Tonsillectomy, anesthesia for, 223 
infiltration block in, 222 
Toxic colloid goiter, cervical block in, 
242 

local anesthesia in, 242 
infiltration in, 242 
novocain-adrenalin in, 
242 

subdermal infiltration in, 
242 

thyroid adenoma, intrathoracic, 
cervical block in, 
243 

local infiltration in, 
243 

saligenin in, 243 

thyroids, 243 

Transoral blocking of mandibular 
nerve, 216 

mandibular block in carcinoma of 
inferior maxilla, 219 
Transplantation of fascia in incisional 
hernia, 407 

Trans-sacral anesthesia in carcinoma of 
rectum, 373 

in pelvic operations, 493 
technic of, 121 

Transverse abdominal incision in 
appendicitis, 473 
cervical nerve, anatomy of, 170 
infiltration block, 275 
Trigeminal nerve, anatomy of, 166 
blocking of, 198 


Tropacocain as local anesthetic, 36 
Tuberculous cervical adenitis, novo¬ 
cain-adrenalin in, 235 
fistula of intestine, local anesthesia 
in, 467 

glands of neck, 232 
peritonitis, local anesthesia in, 467 
infiltration in, 467, 468 
novocain-adrenalin in, 467 
Tumor of brain, 191 

excision of, 192 

of breast, benign, anesthesia in, 
technic of, 251 
infiltration block in, 252 
subdermal infiltration in, 
252 

malignant, 254 

of spinal cord, infiltration block 
in, 269 

local anesthesia in, 269, 
270 

novocain-adrenalin in, 
270 

of uterus, fibroid, local infiltration 
in, 507 

novocain-adrenalin in, 
507 

pelvic splanchnic anes¬ 
thesia in, 507 

Tympanic cavity, anesthesia of, 194 


U 

Ulcer, duodenal, anterior splanchnic 
anesthesia in, 425, 426 
infiltration block in, 423, 425, 
426 

local anesthesia in, 422, 463, 
425 

novocain-adrenalin in, 423 
gastric, anterior splanchnic anes¬ 
thesia in, 424, 425 
local infiltration in, 424 
novocain-adrenalin in, 425 
varicose, of leg, local anesthesia in, 
288 

Ulnar nerve, anatomy of, 173 
Umbilical hernia, local anesthesia in, 
411 

Ununited fracture of femur, local anes¬ 
thesia in, 299 

Ureter, calculi of, direct infiltration of 
abdominal wall in, 325 
local anesthesia in, 323 
technic of, 324 
novocain-adrenalin in, 325 
surgery of, local anesthesia in, 323 
Ureterectomy, local anesthesia in, 319 
Ureterolithiasis, local anesthesia in, 
319, 325 
morphin in, 319 






INDEX 


529 


Ureterolithiasis, paravertebral block 
in, 319 

scopolamin in, 319 
Ureterotomy, local anesthesia in, 325 
Urethra, dilatation of, local anesthesia 
in, 339, 340 

male, stricture of, congenital, 
338, 340 

sacral anesthesia in, 
340 

novocain-adrenalin in, 
339 

sacral anesthesia in, 338 
surgery of, local anesthesia in, 
338 

Uterus, nerve supply of, 352 

operations on, local anesthesia in, 
352 

prolapse of, infiltration block in, 
356 

local anesthesia in, 355 
novocain-adrenalin in, 356 
retroversion of, local anesthesia 
in, 450, 451 

surgery of, local anesthesia in, 495 
tumors of, fibroid, local infiltra¬ 
tion in, 507 

novocain-adrenalin in, 
507 

pelvic splanchnic anes¬ 
thesia in, 507 


V 

Vagina, congenital absence of, infiltra¬ 
tion block in, 358 
local anesthesia in, 358 
novocain-adrenalin in, 
358 

sacral block in, 358 
Vaginal drainage, local anesthesia in, 
361 

examination in virgins, local anes¬ 
thesia in, 348 

hysterectomy, local anesthesia in, 
technic of, 356 
infiltration in, 357 
novocain-adrenalin in, 357 
quinin and urea hydrochloride 
in, 357 


Vagus nerve, anatomy of, 169 
Van Allen method of injecting Gasse¬ 
rian ganglion, 211 
Varicocele, local anesthesia in, 341 
sterilization of skin in, 341 
subdermal infiltration in, 342 
Varicose ulcer of leg, local anesthesia 
in, 288 

veins of leg, local anesthesia in, 
312, 314 
technic of, 313 
novocain-adrenalin in, 
314 

Vasectomy, local anesthesia in, 342 
Vault of skull, fractures of, 190 
Venous anesthesia, 111, 112 
technic of, 112 

Vesical calculus, local anesthesia in, 329 
novocain-adrenalin, 320 
suprapubic infiltration in, 330 
Vesico-ureteral anastomosis, local anes¬ 
thesia in, 327 
Viscera retainer, 106 
Viscero-parietal adhesions, local anes¬ 
thesia in, 401, 451 


W 

Wheal, initial, in introduction of anes¬ 
thetic solution, 149 
Wire-spring retractors, automatic, 97 
Wolff grafts in skin-grafting, local 
anesthesia in, 164 

Wrisberg, nerve of, anatomy of, 169 
Wrist, nerve supply of, 297 

surgery of, local anesthesia in, 297 


Y 

Yellow atrophy of liver, chloroform 
anesthesia and, 28 


Z 

Zygomatic nerve, anatomy of, 167 
Zygomatico-facialis nerve, anatomy of, 
* 168 





































































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